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ON 

SCLEROSIS  OF  THE  SPINAL  COED. 


ON 

SCLEROSIS  OF  THE  SPINAL  COED : 


IXCLUDING 

LOCOMOTOR  ATAXY,  SPASTIC   SPIXAL  PARALYSIS,  AND 

OTHER  SYSTEM-DISEASES  OF  THE  SPINAL  CORD  : 

THEIR  PATHOLOGY,  SYMPTOMS,  DIAGNOSIS, 

AND  TREATMENT. 


BY 


JULIUS   ALTHAUS,  M.D.,  M.R.C.P., 

Senior  Physician    to    the    Hospital  for    Epilepsy    and    Paralysis,    Regents   Park 

Fellow  of  the  Royal  Medical  and  Chirurgical  Society,  of  the  Pathological,  Clinical, 

and  Medical  Societies  of  London ;  Knight  of  the  Order  of  the  Croicn  of  Italy ; 

Corresponding  Member  of  the  JS'ew  Fork  Academy  of  3Iedicine,  of  the 

American  Neurological  Association,  of  the  Electro-Tfierapeutical 

Society  of  New  York,  of  the  SociM  d'Hydrologie  Midicale 

de  Paris,  etc.,  etc.,  etc. 


WITH  XIXE  E2s'GEAVINGS. 


NEW     YORK: 

G.    P.    PUTNAM'S     SONS, 

27    AND    29,  West    Twexty-thirb    Street. 

1885. 
All  Rights  Reserved. 


^c 


LONDON  : 

PRINTED    BY    WEKTHEIMER,    LEA   AND    CO., 

CIRCUS    PLACE,    LONDON   AVALL. 


PREFACE. 


The  subject  of  the  present  volume  is  one  to  which  I 
have  devoted  much  attention,  and  which  I  have  had 
large  opportunities  of  studying  during  the  last  five- 
and-twenty  years  ;  and  I  hope  that  my  labours  may 
go  some  way  towards  dispersing  the  obscurity  which 
at  present  hangs  over  this  department  of  medical 
science.  I  shall  be  especially  gratified  if  my  descrip- 
tion of  the  protean  forms  which  Tabes  Spinalis  or 
Locomotor  Ataxy  is  found  to  assume  in  practice  will 
in  future  lead  to  a  readier  recognition  and  a  more 
successful  treatment  of  that  terrible  malady.  ISo  one 
can  be  more  fully  aware  than  I  am  of  the  gaps  which 
are  still  left  in  our  knowledge  of  several  of  the  spinal 
affections  treated  of  in  this  volume  ;  and  I  have  been 
particularly  careful  to  indicate  these  in  the  course  of 
my  disquisitions,  in  the  hope  of  giving  an  incentive 
to  further  work  in  a  direction  where  it  is  most 
needed. 

48,  IIauley  Street,  Cavendish  Square,  W. 

Sepff/inber,  1884. 
b 


CONTENTS. 


PAGE. 

CHAPTER  I. 

INTRODUCTION. 

Definition  of  Sclerosis  or  Induration — Different  Forms  of  it — 
Systems  of  the  Spinal  Cord — Flechsig's  Eesearches  on  Evo- 
lution —  Burdach's  or  Postero-external  Columns  —  Goll's  or 
Postero-internal  Columns— Direct  Cerebellar  Strands— Crossed 
Pyramidal  Strands — Anomalies  of  Evolution  the  Base  of  the 
Neurotic  Constitution      ....  l 


CHAPTER  II. 

MORBID   ANATOMY    OF    TABES   SPINALIS. 

The  Spinal  Membranes— The  Posterior  Columns— Modes  of  Re- 
search—Hardening and  Staining— Pierret' 8  and  Striimpell's 
Researches  on  Posterior  Sclerosis — Posterior  Nerve-roots — The 
Spinal  Ganglia— The  Central  Grey  Matter— The  Lateral  Columns 
—The  Sympathetic  System  of  Nerves— The  Brain— The  Cranial 
Nerves— the  Spinal  Nerves— Researches  by  Pitres  and  Vaillard 
— Arthropathies     .         .  •■.....       14 

CHAPTER  III. 

PATHOGENESIS    OP    TABES. 

Theories  of  Duchenne  and  Neftel— The  Brain— The  Sympathetic 
System  of  Nerves— The  Posterior  Nerve-roots— Herbert  Page's 
Corn-theory— Spinal  Meningitis— The  Blood  Vessels,  Neuroglia 
and  Tubes  of  the  Posterior  Columns—"  Sensitive  Tabes  "         .38 


Vlll  CONTENTS, 

PAGE. 

CHAPTER  IV. 

MORBID   ANATOMY   OP   OTHER   PORMS   OP    SCLEROSIS. 

Primary  Sclerosis  of  the  Lateral  Columns — Spastic  Spinal 
Paralysis — Erb's  and  Leyden's  Views — Porencephaly — Second- 
ary Sclerosis  of  the  Pyramidal  Strands — Sclerosis  of  the  Direct 
Cerebellar  Strands — Of  GoU's  Columns — Amyotrophic  Lateral 
Sclerosis — Insular  or  Disseminated  Sclerosis  in  Patches — Com- 
bined System-diseases — Friedreich's  Disease — Pseudo- sclerosis  .       51 

CHAPTEE  V. 

ETIOLOGY. 

Ergotism  and  Lathyrism — Barron's  Eesearcbes  on  Lathyrism  in 
Horses — Influence  of  Syphilis — Statistics  of  Syphilitic  Tabes — 
Cases — Complication  of  Secondaries  with  Tabid  Symptoms  — 
Morbid  Anatomy  and  Clinical  Medicine — Period  of  Latency  — 
Influence  of  Cold — Cases  of  Over-exertion — Cases  of  Accidents 
— Cases  of  Venereal  Excesses— Of  Drink — Of  Tobacco-smok- 
ing— Of  Acute  Infectious  Diseases — Of  the  Neurotic  Constitu- 
tion— Causes  of  Friedreich's  Disease— Influence  of  Sex  and  Age 
— Causes  of  Spastic  Spinal  Paralysis— Of  Insular  Sclerosis — Of 
Amyotrophic  Lateral  Sclerosis  ......       68 


CHAPTER  VI. 

SYMPTOMS   OF   TABES   SPINALIS. 

Three  Periods  or  Stages  of  the  Disease        .         .         .        .        .130 

I.   The  First  or  Fre-ataxic  Stage  of  Tabes. 

1.  Loss  of  Knee-jerk   (Westphal's  Symptom)— Its  Physiology 

and  Diagnostic  Importance — Cases — Does  the  Knee-jerk, 
when  once  lost,  ever  come  back  ?— Pseudo-knee-jerk  .     132 

2.  Lightning-pains  ;  their  Description  and  Physiology         .         .     146 

3.  Reflectory  Rigidity  of  the  Pupil  (Argyll-Robertson's  Symptom)     155 

4.  Mydriasis  and  Paralysis  of  the  Ciliary  Muscle         ..        .         .160 

5.  Other  Palsies  of  Ocular  Muscles— Double  Vision— Paralysis  of 

Sixth  and  Third  Nerves— External  and  Internal  Ophthal- 
moplegia   161 

6.  Olfactory  Derangements  :  Anosmia,  Hyperosmia  and  Parosmia     167 

7.  Amblyopia  and  Amaurosis  —  Optic  Atrophy  and  Neuritis- 

Colour-blindness       172 


CONTENTS. 


IX 


PAGE. 


8.  Derangements  of  the  Auditory  Nerve  :  Inflammation  of  it — 

Affection  of  the  Nerve  of  Space — Vertigo. 

9.  Fifth-nerve   Troubles  :  Hypersesthesia — Anaesthesia — Hemi- 

atrophy of  the  Tongue       ....... 

10.  The  Portio  Dura  and  the  Grlosso-pharyngeal  Nerve— Paralysis 

and  Ataxy  of  the  Facial  Muscles       ..... 

11.  Crises  and  other  Symptoms  in  the  Sphere  of  the  Pneumo- 

gastric  Nerve : — 
a.  Laryngeal  Crises— their  Different  Forms. 
h.  Paralysis  of  the  Abductors  of  the  Vocal  Cords 

c.  Spasm  in  the  Gullet. 

d.  Gastric  Crises ..... 

e.  Cardiac  Crises ..... 

12.  The  Spinal  Accessory  Nerve — Torticollis 

13.  Early  Cerebral  Troubles  : — 
a.  Aphasia  and  Paralysis 
h.  Epileptic  Seizures 
c.  Failure  of  Brain  Power    . 

14.  Early  Symptoms  in  the  Sphere  of  Sensibility 
a.  Hypersesthesia         .... 

h.  Parsesthesia 

e.  Ansesthesia       ..... 

15.  Early  Symptoms  in  the  Motor  Sphere    . 

16.  Difficulties  of  the  Bladder  : — 
Sluggishness    . 


a. 

b.  Incontinence 

c.  Vesical  Crises 

17.  Intestinal  Troubles  : — 

a.  Constipation     . 

b.  Diarrhoea 

c.  Intestinal  Crises 

d.  Incontinence     . 

18.  Sexual  Troubles  :  — 
a.  Impotency 
h.  Satyriasis 

c.  Nymphomania 

d.  Spermatorrhoea 

e.  Aspermatism    . 

19.  Perforating  Ulcer  of  the  Foot 

20.  Arthropathies  and  other  Trophic  Affections — Joint-lesions — 

Skin  Diseases— Affections  of  Nails  and  Teeth— Muscular 
Atrophy 


176 


183 


185 


186 
189 
191 
191 
194 
194 

194 
197 
198 
199 
200 
201 
202 
205 

206 

207 
208 

209 
210 
210 
210 

211 
212 
213 
213 
213 
213 


210 


X  CONTENTS. 

PAGE, 

21.  Vasomotor   Symptoms — Hyperidrosis — Anidrosis — Sialorrhoea 

— Gastrorrhoea — Diarrhoea         ......     220 

II.   The  Second  or  Ataxic  Stage  of  Tabes. 

22.  Ataxy  —  The  Initial  Period  —  Tests  for  Ascertaining  it  — 

Eomberg's  Symptom— The  Ataxic  Gait — The  Stage  of 
Muscular  Madness — Acute  Ataxy — Ataxy  in  the  Upper 
Extremities  —  Of  the  Ocular  Muscles  —  Hemi-ataxy — 
Theories  of  Ataxy — Influence  of  the  Central  Ganglia  and 
the  Cerebellum 223 

23.  Sensibility  :    Lightning-pains — Numbness — Amesthesia — An- 

algesias-Anaesthesia Dolorosa — Loss  of  the  Sense  of  Tem- 
perature —  Sense  of  Locality — Of  Pressure  —  Tickling — 
Muscular  Sensibility  .......     250 

24.  Eeflexes 262 

25.  The  Urine 263 

III.   The  Third  or  Terminal  Stage  of  Tabes. 

26.  Late  Brain-troubles  —  General  Paralysis  of    the    Insane — 

Other  Forms  of  Mental  Disease— Modes  of  Death      .         .     263 


CHAPTER  VII. 

THE   DIAGNOSIS    OF    TABES   SPINALIS. 

The  Pre-ataxic  Stage  : — Neursesthenia — Irritable  Spine — Rheu- 
matism and  Gout — Diabetes — Optic  Neuritis — Gastralgia — 
Enteralgia — Ulcer  of  Stomach — Cancer — Local  Diseases  of 
the  Bladder  and  Urethra — Hemiplegia  from  Brain-disease     275 

The    Ataxic     Stage  : — Chorea  —  Paralysis     Agitans  —  Multiple 

Sclerosis — Disease  of  the  Cerebellum — Spinal  Meningitis    .     287 

The  Terminal  Stage '        ....     288 


CHAPTER  VIII. 

THE   PROGNOSIS    OF    TABES    SPINALIS. 

Opinions  of  Various  Authors — Prognosis  now  more  Favourable 
than  formerly — Limited  by  Peculiarities  of  Structure  of 
Affected  Parts — Nerve  Tubes  more  prone  to  Regeneration  than 
Cells — General  Remarks 290 


contp:xts.  xi 

PAGE. 

CHAPTEE  IX. 

THE    TREATMENT    OF    TABES    SPINALIS. 

Eest — Habits — Diet — Anti-syphilitic  Treatment  -  Inunction  and 
Injection — Ergot  of  Eye— Nitrate  of  Silver — Injection  of  Silver 
— Chloride  of  Gold  and  Potassium— Electricity — Faradisation 
of  the  Skin  —  The  Constant  Cuirent  —  Central  and  Local 
Applications — Galvanic  and  Faradic  Baths — Hydropathy — The 
Spas  of  Oeynhausen  and  Nauheim  —  The  Aix-la-Chapelle 
Treatment — The  Waters  of  La  Malou — Nerve -stretching — 
Counter- irritation — Strychnia — Remedies  for  the  Relief  of  Pain 
and  of  other  Symptoms    ........     299 

CHAPTER  X. 

Friedreich's  disease. 

Symptoms — Nystagmus — Absence  of  Sensorial  Troubles — Course 
of  the  Malady — Prognosis  and  Treatment  .         .         .         .324 

CHAPTER  XI. 

SPASTIC    SPINAL   PARALYSIS. 

Its  Pathology  and  Causes — Loss  of  Power — Use  of  Special  Dyna- 
mometer for  the  Lower  Extremities — Its  Value  for  Diagnostic 
Purposes — Symptoms  of  Motor  Irritation — Influence  of  the 
"Warm  Bath — The  Spastic  Gait — Progress  of  the  Disease — Exag- 
geration of  Tendon  Reflexes — Ankle  Clonus  and  Ejiee-jerk — 
Direct  Percussion  of  Muscular  Substance — Differences  in 
Type  :  the  Cerebral,  Spinal,  and  Muscular  Types — Anatomical 
Cause  of  the  Exaggeration  of  Reflexes — Increased  Reflexes 
without  Paralysis — Affection  of  Sensibility — Cases — Diagnosis 
from  Tabes,  Transverse  Myelitis,  Cerebral  Hemiplegia, 
Hysteria,  Pseudo- Sclerosis,  Amyotrophic  Lateral  Sclerosis 
and  Insular  Sclerosis — Prognosis— Treatment  ....     328 

CHAPTER  XII. 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

Affection  of  Upper  Extremities — Of  Lower  Extremities — Signs  of 
Labio-glosso-laryngeal  Paralysis  —  Diagnosis  —  Prognosis — 
Treatmnnt        ....  ,  .....     347 


Xll  CONTENTS. 

PAGE. 

CHAPTER  XIII. 

SECONDARY   LATERAL    SCLEROSIS. 

Descending  Sclerosis  of  Pyramidal  Strands  after  Cerebral 
Lesions — Destruction  of  tlie  Internal  Capsule  Indispensable  for 
its  Production  —  Symptoms — Prognosis — Treatment — Spastic 
Paralysis  in  Children — Porencephaly — Injury  from  Obstetrical 
Operations — Epileptic  Fits — Other  Symptoms — Prognosis  and 
Treatment^- Secondary  Sclerosis  after  Haemorrhage  into,  and 
Crushing  Lesions  of,  the  Spinal  Cord — Case     ....     350 

CHAPTER  XIV. 

SCLEROSIS    OF    GOLL's    COLUMNS 362 

CHAPTER  XV. 

MULTIPLE    OR   INSULAR   SCLEROSIS. 

Symptoms  of  the  First  Stage — Apoplectiform  Seizures — Loss  of 
Power — Symptoms  in  Children — In  the  Sphere  of  Sensibility — 
Tremor — Its  Symptoms  and  Pathology — Case — Its  Difference 
from  Paralysis  Agitans,  Chorea  and  Tabes — Vertigo — Drawling 
Speech — Eye-Symptoms — Anosmiaand  Deafness — State  of  Deep 
Reflexes — The  Bladder,  Rectum,  and  Sexual  Organs — Amenor- 
rhoea — Symptoms  of  Second  and  Third  Stages — Diagnosis  :  from 
Friedreich's  Disease,  Spastic  Paralysis,  and  Pseudo- sclerosis — 
Prognosis  and  Treatment 363 

CHAPTER  XVI. 

PSEUDO- SCLEROSIS. 

Symptoms  of  Sclerosis  without  Anatomical  Lesions — Cases  .     381 

CHAPTER  XVII. 

COMBINED   POSTERO- LATERAL   SCLEROSIS. 

Different  Anatomical  Localisations  and  Symptoms — Diagnosis      .     383 

Index  op  Authors 387 

Index  op  Subjects 391 


ON 

SCLEEOSIS  OF  THE  SPINAL  COED. 


CHAPTER    I. 

INTRODIJCTION. 

There  is  no  pathological  term  which  is  now-a-days  so  freely 
and  somewhat  loosely  used  in  speaking  and  writing  about 
the  diseases  of  the  nervous  system   as  the  word  sclerosis. 
We   hear   and  read  not   only    of   primary  and    secondary 
sclerosis,    but   also    of    posterior   and   lateral  sclerosis,  of 
descending   and   ascending,    and  of  insular,    disseminated 
and  amyotrophic    sclerosis.     From   having   been   at    first 
simply   used  for    designating  certain  morbid   appearances 
found   post-mortem   in    various   portions    of    the    nervous 
system,  the  term  has  gradually  come  to  be  employed  for 
the  nomenclature  of  diseases,  tabes  dorsalis  or  locomotor 
ataxy  being    now   frequently    called    posterior    sclerosis, 
and   spastic  paralysis  being  termed  lateral  sclerosis.     In 
practice,    any     obscure    and     chronic     case     of     nervous 
disease  is  now  often  spoken  of  as  "a  case  of  sclerosis," 
which  is   supposed  to  explain  everything,  and  it  cannot 
be  denied  that  there  is  a  good  deal  of  confusion  in  the  pro- 
fessional  mind   about    what    sclerosis    really    means    and 
comprehends  ;  while  the  subject  is  so  important  that  clear 
notions  concerning   it  are   highly  desirable.      Much  that 
is  new  has   recently  been   added   to   this  department   of 
pathology,  and  has,  as  usual,  led  to  considerable  improve- 
ment in  diagnosis  and  treatment. 

B 


2  SCLEROSIS  OF  THE  SPINAL  CORD. 

Although  the  term  sclerosis  (from  o-fcXi?jooc,  hard),  or 
induration,  is  therefore  now  applied  to  a  great  variety  of 
diseases  of  the  spinal  cord,  it  should  be  understood  that 
we  do  not  invariably  find  a  very  pronounced  hardening  of 
the  structures  which  are  affected  in  such  cases.  In  some 
few  instances,  indeed,  and  notably  so  where  the  disease 
is  comparatively  fresh,  the  parts  may  actually  appear  to 
be  softened  ;  but  where  the  morbid  process  has  been  going 
on  for  a  considerable  time,  as  is,  indeed,  most  frequeutly 
the  case,  the  diseased  tissues  are  decidedly  tougher  and 
harder  than  the  normal  ones,  and  may  therefore  be  properly 
called  sclerosed. 

By  sclerosis  of  the  spinal  cord  I  understand,  then,  an 
irritant  morbid  process,  standing  intermediate  between  inflamma- 
tion and  simple  atrophy^  which  invades  certain  well-defined  and 
evolutionally,  anatomically,  and  physiologically  distinct  areas 
or  systems  of  that  organ ;  and  which  leads  in  course  of  time  to 
disintegration  and  wasting  of  the  nerve-tubes,  very  generally 
to  partial  or  comjjlete  destruction  of  the  axis-cylinder,  and 
to  overgrowth  of  connective  tissue.  The  best  known  of 
these  affections  is  one  with  which  we  have  long  been 
familiar  as  tabes  dorsalis,  more  recent  synonyms  being  ^^ro- 
gressive  locomotor  ataxy  (Duchenne),  progressive  locomotor 
asynergy  (Trousseau),  scZerosxs  of  the  posterior  columns  (Erb), 
din^  posterior  leuco-myelitis  (Vulpian).  The  name  locomotor 
ataxy  does  not  appear  to  have  been  happily  chosen,  as  the 
ataxy  of  gait,  which  constitutes  the  most  prominent  symp- 
tom of  the  fully-developed  malady,  is  in  many  cases  absent 
for  years  after  the  outbreak  of  the  disease;  the  same  applies 
to  Trousseau's  "  asynergy  ";  while  the  other  terms  just  men- 
tioned only  refer  to  the  pathological  anatomy  of  the  com- 
plaint. The  old  term  "tabes"  therefore  appears  to  be  the 
best,  and  is  now  again  gradually  replacing  the  more  recent 
appellations  which  had  for  some  time  past  reigned  supreme 
in  the  text-books  and  medical  journals. 

An  apparently  analogous  affection  of  the  lateral  columns 


INTRODUCTION. 


of  the  cord  has  only  recently  been  introduced  into  our 
system  of  nosology  by  Erb,  who  has  called  it  spastic  spinal 
paralysis  ;  while  Charcot,  who  had  investigated  this  subject 
about    the    same  time  independently,  termed  the  disease 


O-ff 


ceo 


Transverse  section  of  the  spinal  cord  of  the  adidt :  af,  anterior 
fissure  ;  pf,  posterior  fissure ;  c,  spinal  canal  ;  ac,  anterior  columns ; 
Ic,  lateral  columns ;  pc,  posterior  columns ;  ah,  anterior  horns  ;  ph,  pos- 
terior horns;  gs,  gelatinous  substance  ;  cc,  Clark's  columns;  gc,  Goll's 
columns  ;  be,  Burdach's  columns  ;  k,  anterior  commissure ;  gg,  ganglion 
cells  of  the  anterior  horns  ;  pio,  bloodvessels  of  the  pia  mater ;  «r, 
anterior  roots ;  pr,  posterior  roots. 

spasmodic  tabes  dorsalis.  Synonymous  terms  are  primary 
lateral  sclerosis  (Berger),and  sclerosis  of  the  pyramidal  strands 
(Dreschfeld).  Ley  den,  however,  denies  the  existence  of 
this  affection  as  a  separate  disease  ;    and  as   only    slight 

b2 


4  SCLEROSIS  OF  THE  SPINAL  COED. 

evidence  for  it  has  as  yet  been  furnished  by  morbid 
anatomy,  the  term  "  spastic  paralysis  "  appears  preferable, 
as  it  does  not  commit  us  to  any  definite  theory  about  the 
nature  of  the  malady. 

No  doubt  exists  about  the  occurrence  of  a  combined 
affection  of  the  white  lateral  columns  and  the  grey  anterior 
cornua,  which  was  first  distinguished  by  Charcot,  and 
termed  by  him  amyotrophic  lateral  sclerosis,  the  chief 
symptoms  being  motor  paresis  and  rigidity,  followed 
by  atrophy  of  the  muscular  fibre.  Another  primary 
affection  of  this  kind  is  multiple^  insular,  or  dissemi- 
nated sclerosis,  which  is  also  called  sclerosis  in  patches, 
and  which  may  affect  not  only  the  different  portions  of  the 
cord,  more  especially  its  antero-lateral  columns,  but  also 
the  medulla  oblongata,  pons  varolii,  the  central  white  sub- 
stance of  the  cerebellum,  and  the  medullary  substance  of  the 
cerebral  hemispheres.  In  this  disease  the  morbid  process 
is,  as  a  rule,  not  so  severe  as  in  tabes  ;  for  while  in  the 
latter  the  nerve-fibre  eventually  perishes  altogether,  that 
important  portion  of  it  which  is  known  as  the  axis- 
cylinder  appears  often  to  be  spared  in  insular  sclerosis. 
There  are  further  anatomical  differences  between  this 
and  other  forms  of  sclerosis,  which  will  be  fully  described 
hereafter. 

All  forms  of  primary  sclerosis  are  symmetrical,  and  only 
exceptionally  confined  to  one  half  of  the  organ. 

Secondary  sclerosis,  on  the  other  hand,  is  mostly  uni- 
lateral, and  is  the  result  of  some  other  primary  disease,  such 
as  haemorrhage  into  the  brain,  softening  of  the  cerebral  sub- 
stance from  embolism  or  thrombosis  of  blood-vessels,  or 
of  hfBmorrhage  into  the  substance  of  the  cord,  and  acute 
myelitis,  Pott's  disease  of  the  vertebrae  with  compression 
of  the  cord,  etc.  When  it  occurs  after  destructive  lesions  of 
the  motor  area  of  the  brain,  it  affects  only  that  portion  of 
the  cord  which  corresponds  physiologically  to  the  dis- 
eased hemisphere,  that  is,  the  crossed  pyramidal  column, 


INTRODUCTION.  5 

and  Tiirck's  anterior  or  the  direct  pyramidal  column.  In 
these  latter  strands  the  disease  occurs  in  a  descending 
direction,  while  where  secondary  sclerosis  affects  the 
postero'internal  or  Goll's  columns,  it  takes  place  in  an 
ascending  direction. 

Clinical  observation  as  well  as  morbid  anatomy  seem  to 
point  to  the  conclusion  that  all  these  different  diseases  are 
very  closely  allied  to  each  other  in  character  and  appear- 
ances, and  differ  more  particularly  according  to  localisation. 

It  is  a  fact,  which  stands  out  more  clearly  as  our  know- 
ledge advances,  that  fibres  which  have  certain  functions  in 
common  are  liable  to  become  diseased  together  at  exceed- 
ingly different  levels  of  the  cord,  while  others  in  their 
immediate  neighbourhood,  which  have  different  functions, 
are  spared.  Moreover,  such  fibres  are  liable  to  be  affected 
symmetrically  in  the  two  lateral  halves  of  the  organ,  the 
degree  of  the  morbid  change  being  often  exactly  parallel  in 
both  sides  of  the  cord.  The  differences  in  the  physiological 
function  are  naturally  correlated  to  evolutional,  anatomical, 
and  possibly  also  to  chemical  differences  in  the  several 
parts.  Indeed,  the  cord  consists,  like  the  hrain,  of  a  number 
of  different  areas  or  systems,  each  of  which,  although  it  may 
be  histologically  identical  with  others,  yet  follows  a  special 
type  of  evolution  in  the  foetus,  has  different  connections  with 
more  peripheral  and  more  central  parts,  may  possibly  be 
chemically  quite  distinct  from  its  surroundings,  and  lastly 
possesses  peculiar  pathological  predispositions  or  proclivities 
which  are  not  shared  by  contiguous  parts,  however  closely 
connected  with  them  in  anatomical  position,  and  however 
similar  in  histological  elements. 

An  apt  illustration  of  these  peculiarities  is  afforded  by 
the  manner  in  which  different  poisons  act  on  the  different 
portions  of  the  cord.  Bread  contaminated  with  ergot  of 
rye  will,  when  habitually  taken  for  some  time,  cause  well- 
marked  disease  of  the  posterior  columns  ;  while  bread 
containing  an  admixture  of  the  laihyrus  cicera,  which  is  eaten 


6  SCLEROSIS  OF  THE  SPINAL  CORD. 

bj  the  lower  classes  in  certain  parts  of  India,  Algeria  and 
Italy,  will  lead  to  equally  striking  symptoms  of  disease  of 
the  lateral  columns.  Strychnia  has  a  special  influence  in 
exalting  the  excitability  of  the  grey  centre  of  the  cord, 
and  bromide  of  potassium  diminishes  it.  Finally,  lead  will, 
when  absorbed  for  some  time  consecutively,  cause  gradual 
disintegration  of  the  large  ganglionic  cells  of  the  grey 
anterior  cornua,  and  thus  lead  to  a  peculiar  form  of  mus- 
cular atrophy. 

In  order,  therefore,  to  render  the  more  minute  pathology 
of  the  diseases  under  consideration  thoroughly  intelligible, 
it  will  be  necessary  for  me  to  enter  first  into  some  explana- 
tion of  the  manner  in  which  the  highly  complex  structure 
of  the  spinal  cord  is  built  up  and  arranged.  Histology  and 
experimental  physiology  have  done  very  little  for  the  eluci- 
dation of  this  subject,  while  the  study  of  evolution  on  the 
one  hand,  and  of  the  finer  pathological  anatomy  of  the 
degenerations  to  which  the  organ  is  liable  on  the  other  hand, 
have  been  of  the  greatest  service  for  unravelling  the  inti- 
mate structure  and  arrangement  of  the  organ.  Either  of 
these  methods  of  inquiry  may  be  used  for  controlling  the 
results  given  by  the  other,  thus  affording  a  greater  degree 
of  reliability  than  each  one  singly  could  do. 

With  regard  to  evolution,  Flechsig^  has  shown  that  the 
central  nerve-fibre  is  at  first  laid  down  as  a  naked  axis- 
cylinder,  and  that  this  latter  is  only  much  later  furnished 
with  a  sheath  of  myeline.  The  latter  is  therefore  a  second- 
ary formation,  and  is,  in  the  several  portions  of  the  cord, 
developed  at  totally  different  periods  of  foetal  life,  just  as 
well  as  the  axis-cylinder  itself.  This  mode  of  evolution 
follows  a  definite  law  with  regard  to  time  ;  and  it  may  thus 
be  understood  why  tracts  of  fibres  which  are,  anatomically 
speaking,  at  a  considerable  distance  from  each  other,  are, 


1  (I 


"  Die  Leitungsbahnen  ua  Gehirn  und  Riickenmark  des  Menschen." 
Leipzig,  1876. 


INTRODUCTION. 


in  fact,  far  more  closely  related  tlian  others  which  may  be 
much  nearer  neighbours. 

The   succession  in  which  the  evolution  of  the  diSerent 
portions  of  the  cord  takes  place,  is  as  follows  : — 

1st.  The  fundamental  strands  of  the  anterior  columns  ; 

2nd.  The  postero-external  or  Burdach's  columns  ; 

3rd.  The  anterior  mixed  zone  of  the  lateral  columns  ; 

4th.  The  lateral  terminal  layer  of  grey  matter  ; 

5th.  The  postero-internal  or  Goll's  columns  ; 

6th.  The  direct  cerebellar  columns  ;  and,  finally, 

7th.   The  crossed  pyramidal  strands. 

p 


Section  of  the  spinal  cord  from  the  region  of  the  5th  cervical  nerve 
from  a  foetus  12  centimetres  long  (after  Flechsig).  P,  Tiirck's  anterior 
pyramidal  column ;  A  C,  fundamental  tracts  of  the  anterior  columns ; 
ALC,  anterior  mixed  lateral  column;  pc^  processus  reticulares  ;  CP, 
crossed  pyramidal  columns  ;  By  Burdach's  columns ;  G,  GoU's  columns. 

Of  these  seven  different  strands  of  the  cord,  those  num- 
bered 1,  2,  and  3,  viz.,  the  fundamental  strands  of  the 
anterior  columns,  Burdach's  columns,  and  the  anterior  zone 
of  the  lateral  columns,  become  developed  at  the  earhest 
period  of  foetal  life.  The  naked  axis-cylinders  are  laid 
down  at  the  end  of  the  fourth  week,  and  their  myeline 
sheaths  appear  to  be  fully  formed  about  the  end  of  the  fifth 
month,  so  that  about  four  months  are  required  for  their 


8  SCLEROSIS  OF  THE  SPINAL  COED. 

completion.  These  three  strands  have  another  feature  in 
common,  viz.,  that  their  transverse  section  differs  at  different 
levels  of  the  cord,  being  greatest  in  the  cervical  en- 
largement. The  size  of  the  transverse  section  is  propor- 
tionate to  the  number  of  nerve-fibres  which  enter  the 
strands.  From  this  it  is  concluded  that  a  large  portion  of 
the  longitudinal  fibres  contained  within  these  strands  do 
not  remain  in  the  white  matter  of  the  cord,  but  leave  it, 
after  a  longer  or  shorter  course  within  the  same,  in  order 
to  proceed  into  the  grey  matter  of  the  organ,  where  they 
terminate.  They  therefore  connect,  on  the  one  hand, 
the  grey  matter  of  the  cord  with  peripheral  terminal 
organs,  and  on  the  other  hand,  different  levels  of  the  cord 
with  each  other. 

BurdacVs  or  the  postero-external  columns  (B,  Fig.  2)  are 
of  chief  interest  for  us  here,  as  they  appear  to  be  principally 
selected  by  the  morbid  process  in  tabes.  These  columns  are 
the  bandelettes  externes,  or  rubans  externes,  or  zones 
radiculaires  posterieures  (posterior  root-zones)  of  the  French 
anatomists.  The  term  "Burdach's  columns,"  however,  is 
the  most  convenient  and  the  most  generally  accepted. 

The  transverse  section  of  these,  columns  shows  great 
variations.  In  the  cervical  enlargement  they  are  more 
than  twice  the  size  of  what  they  are  in  the  middle  dorsal 
portion,  and  in  the  lumbar  enlargement  only  two-thirds  of 
it.  Their  upper  portion  terminates  in  the  nuclei  of  the 
funicuH  cuneati  of  the  medulla  oblongata.  They  are  the 
direct  continuations  of  the  posterior  root-fibres,  and  therefore 
establish  a  direct  and  immediate  connection  of  the  cord 
with  peripheral  parts,  and  thereby  with  external  influences. 
They  are  short  conducting  paths,  inasmuch  as  the  posterior 
root-fibres,  which  enter  into  them  throughout  their  course, 
traverse  them  in  a  horizontal  direction,  or  bend  upwards 
or  downwards  to  assume  a  longitudinal  direction.  When, 
therefore,  at  a  given  level  of  the  cord  numerous  root-fibres 
enter,  the  calibre  of  the  columns  must  be  greater  than  where 


INTRODUCTION. 


the  root  fibres  are  few.  On  the  median  side  of  the  posterior 
horns  numerous  fibres  proceed  from  Burdach's  columns 
into  the  grey  matter  of  the  cord,  in  a  direction  partly 
towards  the  posterior  commissure,  partly  towards  the  pos- 
terior cornua,  and  partly  towards  Clarke's  columns. 

These  parts  contain  fibres  which  connect  different  levels 
of  the  grey  matter  with  each  other,  and  others  which  pro- 
ceed into  the  medulla  oblongata.  Most  of  them  appear  to 
terminate  in  the  ganglionic  cells  of  the  formatio  reticularis 
of  the  bulb,  while  another  part  communicates  with  the 
nuclei  of  the  caudate  columns  and  the  corpora  olivaria. 

The  French  school  of  anatomists,  as  represented  chiefly 
by  Charcot,  Vulpian,  and  Pierrot,  have  long  taught  that  in 
tabes  the  morbid  process  begins  in  Burdach's  columns,  and 
that  the  internal  portions  of  the  posterior  columns  are  only 
affected  much  later  on,  when  the  disease  spreads  to  other 
parts.  This  proposition  has  for  some  time  past  been 
generally  accepted;  but  more  recent  researches  by  German 
anatomists,  more  especially  by  Striimpell,  of  Leipzig,  have 
shown  that  such  is  not  by  any  means  invariably  the  case; 
but  that,  at  least  in  a  certain  number  of  instances,  the 
most  internal  portion  of  G-oll's  columns  becomes  sclerosed 
in  the  very  commencement  of  the  disease. 

No  definite  law  has  as  yet  been  formulated  with  regard 
to  No.  4,  the  lateral  terminal  layer  of  the  grey  matter. 

The  postero-internal,  or  posterior  median,  or  GolVs 
columns  {G,  Figs.  1  and  2),  are  laid  down  at  the  end  of  the 
second  month,  and  the  formation  of  their  myeline  sheaths 
appears  to  be  finished  at  the  end  of  the  sixth  month,  giving 
again  a  period  of  four  months  for  the  entire  process.  These 
strands  may  only  be  clearly  traced  separately  in  the  cervical 
and  upper  dorsal  portions  of  the  cord,  and  cannot  be  easily 
followed  lower  down.  Their  transverse  section  increases 
in  diameter  in  a  direction  from  below  upwards,  and  they 
do  not  give  fibres  to  the  grey  matter  of  the  cord,  but 
receive  them  from  it;  indeed  their  origin  is   in  the  grey 


10  SCLEROSIS  OF  THE  SPINAL  CORD. 

matter  of  the  cord.  These  fibres  proceed  from  the  internal 
aspect  of  the  posterior  cornua,  and  more  especially  from 
Clarke's  columns  and  their  immediate  neighbourhood,  and 
the  posterior  commissure.  Although  GoU's  columns  are 
only  well  seen  separate  in  the  cervical  cord,  there  can  be 
little  doubt  that  they  course  all  the  way  from  the  medulla 
oblongata  to  the  lumbar  enlargement,  where  their  size  is 
smallest.  They  terminate  upwards  in  the  nuclei  of  the 
funiculi  graciles,  and  have  to  be  looked  upon  as  a  special 
system  of  fibres  on  account  of  the  quality  and  calibre  of 
the  nerve-tubes  composing  them,  of  their  origin  in  the  grey 
matter,  and  their  relation  to  certain  nuclei  in  the  medulla 
oblongata.  While  Burdach's  columns  are  short  conducting 
paths,  Groll's  columns  must  be  considered  long  conduct- 
ing paths,  intended  to  connect  certain  extra-medullary 
centres  in  the  brain  and  cerebellum  with  physiologically 
identical  fibre-systems  at  different  levels  of  the  cord. 

The  next  system  of  fibres  is  called  the  direct  cerebellar 
strands  {Ce,  Figs.  1  and  2).  They  are  laid  down  at  the 
commencement  of  the  third  month,  while  fully  formed 
myeline-sheaths  are  first  observed  at  the  beginning  of  the 
seventh  month,  making  again  a  period  of  four  months 
taken  up  for  their  completion.  They  contain  fibres 
establishing  a  connexion  between  the  grey  matter  of  the 
cord — probably  more  particularly  Clarke's  vesicular  columns 
— and  cerebellar  centres.  The  fibres  of  these  strands  are 
shown  to  constitute  a  special  system  by  the  following 
points: — They  spread  equally  in  the  grey  matter  of  the 
cord,  behave  equally  within  the  lateral  columns,  and  have 
an  equal  course  in  the  medulla  oblongata.  At  the  time  of 
birth  these  strands  may  be  seen  sharply  defined  in  the 
cervical  cord,  and  are  quite  apart  from  the  other  portions 
of  the  lateral  columns.  They  show  a  continuous  increase 
in  their  transverse  section,  in  a  direction  from  below 
upwards,  and  may  be  traced  as  compact  strands  to  the 
upper  portion  of  the  lumbar  enlargement  only. 


INTRODUCTION.  11 

Tlie  last  system  of  fibres  which  we  have  to  consider 
(7)  is  that  known  as  the  crossed  pyramidal  strands. 
(CP,  Figs.  1  and  2.)    These  are  the  latest  of  all  formations. 


Section  of  the  spinal  cord  from  the  middle  portion  of  the  cervical 
enlargement  of  a  foetus,  35  centimetres  long  (after  Flechsig) .  P,  anterior 
pyramidal  strand ;  AE,  anterior  roots ;  Ce,  direct  cerebellar  columns  ; 
CF,  crossed  pyramidal  strands ;  £,  Burdach's  columns ;  G,  GoU's 
columns.     Magnified  6*4  lin. 

They  are  first  laid  down  about  the  middle  of  the  fifth 
month,  and  the  formation  of  their  myeline-sheaths  is  only 
finished  about  the  end  of  the  ninth  month,  so  that  again  a 
period  of  four  months  is  seen  to  elapse  between  their 
beginning  and  their  eventual  completion.  These  strands 
contain  exclusively  fibres  which  are  in  connection  with  the 
cerebral  hemispheres,  through  the  pyramids  of  the  medulla 
oblongata  and  the  higher  motor  tracts;  and  they  communi- 
cate with  certain  accumulations  of  grey  matter  in  the 
brain,  more  especially  the  lenticular  nucleus  and  the 
central  convolutions  of  the  cortex. 

In  other  words,  they  contain  all  the  fibres  which  form  a 
direct  connection  between  the  grey  matter  of  the  cord,  the 
central  ganglia,  and  the  motor  portion  of  the  cortex  of  the 
brain.  They  therefore  constitute  likewise  a  special  system 
of  fibres,  having  its  own  definite  peculiarities  and  termina- 
tions.    They  have  this  feature  in  common  with  the  direct 


12  SCLEROSIS  OF  THE  SPINAL  CORD. 

cerebellar  strands,  that  there  is  a  steady  increase  in  the 
diameter  of  their  transverse  section  in  a  direction  from 
below  upwards.  They  are  situated  in  the  posterior  half  of 
the  lateral  columns,  and  may  be  traced  down  as  far  as  the 
lower  end  of  the  lumbar  enlargement,  or  to  the  third  or 
fourth  sacral  nerve.  They  diminish  in  transverse  section 
from  above  downwards,  owing  to  their  fibres  successively 
entering  the  grey  centre  of  the  cord  in  that  portion  of  it 
which  connects  the  anterior  and  posterior  cornua.  They 
show  immense  individual  variations  in  extent,  inasmuch 
as  the  fibres  which  proceed  from  the  motor  region  of  the 
brain  into  the  cord  have  the  choice  to  course  either  in  the 
same  anterior,  or  the  opposite  lateral,  column,  before  they 
proceed  into  the  central  grey  matter. 

From  the  foregoing  description  it  appears  that  the  dif- 
ferent conducting  paths  in  the  spinal  cord  are  laid  down  and 
developed  in  an  absolutely  systematic  manner,  and  that  at  the 
same  period  of  intra-uterine  existence  only  one  or  several 
allied  systems  are  formed.  Those  which  are  most  im- 
portant for  the  life  of  the  foetus  and  which  are  reflectory  by 
nature,  are  early  developed,  their  faculty  of  incessant 
function  being  an  indispensable  condition  for  viability 
altogether.  On  the  other  hand,  those  tracts  which  place 
the  spinal  cord  under  the  influence  of  the  psychomotor 
centres,  or  the  will,  become  evolved  at  a  later  period. 
These  latter  are  more  abundantly  developed  in  man  than 
in  the  lower  animals,  and  are  not  formed  at  all  in  con- 
genital absence  of  the  brain,  or  in  destructive  disease  of 
the  motor  area  of  the  same. 

As  far  as  size  is  concerned,  the  anterior  columns  have 
been  found  to  contain  on  the  average  18  per  cent.,  the 
lateral  columns  46*6,  and  the  posterior  columns  35*4  per 
cent,  of  the  white  matter  of  the  cord. 

Anomalies  of  anatomical  growth  have  probably  a  con- 
siderable influence  on  the  evolution  of  diseases  which 
occur  later  in  Hfe.    They  may  possibly  be  found  eventually 


INTRODUCTION. 


IS 


to  be  the  chief  material  base  of  what  is  now  called  the  neurotic 
constitution.     Congenital  fissures    or    cavities  may  be  the 
starting-point  of  certain  diseases,  causing  tendency  to  the 
formation  of  glioma,   glio-sarcoma,    or  chronic  interstitial 
or  parenchymatous   degeneration.      Singular   irregularities 
in  the  distribution  of  the   white   and  grey   matter  are  not 
rarely  met  with  in  persons  who  have  died  of  diseases  of 
the  nervous  system.     Schultze  has  found  such  anomalies 
in  cases  of  spastic  paralysis  and  general  paralysis  of  the 
insane.     Kahler  and  Pick  discovered,  in  a  person  who  had 
died  of  tabes,  abnormal  smallness  and  irregular  shape  of  the 
central  grey  matter,  and  extreme  smallness  of  the  posterior 
columns,  which  was  not  exclusively  owing  to  degeneration. 
As  there  are  born  statesmen,  artists,  and  criminals,  so  there 
are  no  doubt  some  born  to  be  sclerosed,  and  these  are  in 
general  the  descendants  of  the  syphilitic,  the  gouty,  and  the 
alcoholised.     The  gradual  formation  of  the  myeline  sheaths 
of  the  central  nerve-fibre,  which  has  been  shown  to  follow 
a  definite  law  throughout  embryonic  life,  may  in  some  cases 
be  carried  out  in  a  deficient  manner,  and  this  may  later  on 
lead  to  disease  of  the  imperfectly  formed  or  not  fully  pro- 
tected parts.   Where  undue  claims  are  made  upon  a  small  or 
badly  formed  medulla  oblongata  or  spinal  cord,  where  con- 
nective tissue  predominates  over  nerve-cells  or  fibres,  there 
must  be  greater  tendency  to  the  development  of  asthma, 
diabetes,  tabes,   or  paralysis,  than  there  will  be  in  cases 
where  the  essential  constituents  of  these  organs  have  been 
more  abundantly  and  perfectly  developed^ 


14  SCLEROSIS  OF  THE  SPINAL  CORD 


CHAPTER  11. 

MOEBID  ANATOMY  OF  TABES  SPINALIS. 

The  post-mortem  appearances  in  tabes  have  been  studied 
by  a  very  large  number  of  observers,  and  the  main  facts 
connected  with  them  appear  now  to  be  tolerably  well  as- 
certained, although  opinions  still  differ  widely  with  regard 
to  their  interpretation. 

1.  With  regard  to  the  spinal  membranes,  it  is  found  that 
the  dura  mater  is  habitually  normal,  while  the  arachnoid 
may  be  opaque,  and  the  pia  mater  is  frequently  congested 
and  thickened  at  the  level  of  the  posterior  columns.  The 
spinal  fluid  is  increased,  and  sometimes  to  a  considerable 
extent.  The  trabeculse  which  traverse  the  sub-arachnoid 
space  may  be  thickened  and  more  abundant  than  in  the 
normal  condition.  The  thickening  of  the  membrane  and 
the  hyperaemia  of  the  vessels  of  the  pia  mater  become 
gradually  less  towards  the  region  of  the  lateral  columns, 
and  are  in  the  majority  of  cases  more  pronounced  in  the 
dorso-lumbar  than  in  the  cervical  region  of  the  cord. 
Posterior  spinal  le2')to-meningitis  has,  therefore,  to  be  looked 
upon  as  an  habitual  concomitant  of  tabes,  more  especially 
where  the  disease  is  seen  in  an  advanced  stage. 

2.  The  most  constant,  most  decided,  and  earliest  change, 
however,  is  found  in  the  posterior  columns  of  the  cord, 
which  show  a  definite  lesion  recognizable  by  the  micro- 
scope at  a  time  when  the  clinical  symptoms  have  only 
commenced  to  manifest  themselves,  and  when  the  parts 
appear  perfectly  normal  to  the  naked  eye.  Where  tabes 
has  lasted  for  years,  as  is  usually  the  case,  the  unassisted 


MORBID    ANATOMY    OF    TABES    SPINALIS.  15 

eye  recognises  the  appearances  of  grey  induration,  or 
sclerosis  in  the  posterior  columns  ;  that  is,  these  parts 
appear  flattened  and  reduced  in  their  transverse  diameter, 
while  their  colour  has  changed  from  white  to  grey.  In  some 
cases  the  discoloration  is  more  pinkish,  reddish,  or  yellowish. 
This  alteration  is  generally  more  marked  in  the  lower  and 
middle  portions  of  the  cord,  and  diminishes  gradually  in 
the  direction  towards  the  medulla  oblongata,  on  the 
one  hand,  and  the  cauda  equina  on  the  other  hand. 
The  tissue  of  the  posterior  columns  is  firmer  and  touo-her 
than  in  health,  and  really  sclerosed;  but  in  exceptional 
cases  the  consistency  is  normal,  or  may  appear  even  softer 
than  usual.  These  differences  are  owing  to  the  variations 
in  the  overgrowth  of  connective  issue,  which  is  in  the 
majority  of  cases  very  marked,  but  in  some  less  per- 
ceptible. As  a  rule,  the  degeneration  does  not  spread 
beyond  the  medulla  oblongata,  but  occasionally  a  certain 
amount  of  corresponding  change  has  been  seen  in  the 
superficial  layers  of  the  pons  varolii  and  the  corpora  qua- 
drigemina. 

The  real  nature  of  the  morbid  alteration  which  has  taken 
place  is  only  revealed  after  hardening  and  staining  the  cord 
in  various  fluids  and  by  microscopic  examination  of  fine 
sections.  Gerlach  and  Lockhart  Clarke  were  the  first  to 
introduce  the  process  of  hardening  the  organ  by  chrome, 
and  used  for  this  purpose  a  0-25  per  cent,  solution  of 
crystallized  chromic  acid.  It  was,  however,  soon  dis- 
covered that  this  does  not  harden  the  parts  so  thoroughly 
and  uniformly  as  the  chrome-salts.  One  of  the  most 
useful  preparations  of  the  latter  kind  is  MuUer's  fluid, 
which  consists  of  one  part  of  sodium  sulphate  and  two 
and  a  half  parts  of  potassium  bichromate  in  a  hundred 
parts  of  water.  By  immersion  into  this  fluid,  the  cord  is 
not  only  hardened,  and  therefore  better  suited  for  section, 
but  the  diseased  parts  are  rendered  more  clearly  perceptible 
by  remaining  light  coloured,  while  the  healthy  parts  absorb 


16  SCLEROSIS  OP  THE  SPINAL  CORD. 

the  chrome-salt  readily,  and  therefore  assume  a  darker 
colour.  Another  excellent  agent  for  hardening  and  staining 
the  cord  is  a  one  per  cent,  solution  of  osmic  aeid,  as  recom- 
mended by  Exner,  of  Vienna.  In  France  this  method  is 
generally  described  as  Ranvier's.  Osmic  acid  has  the, 
pecuharity  of  deeply  staining  the  myeline  sheath  of  the 
central  nerve-fibre,  which  appears  blackened,  but  has  no 
eSect  on  the  axis-cylinder.  It  is  therefore  well  supple- 
mented by  a  solution  of  anihne  blue-black,  in  the  proportion 
of  one  to  four  hundred  parts  of  water,  which  has  been 
introduced  by  Bevan  Lewis.  This  latter  fluid  has  just 
the  opposite  effect,  since  it  leaves  the  medullary  sheath 
unaltered,  but  imparts  a  deep  blackish  stain  to  the  axis- 
cylinder.  Charcot  and  Vulpian  employ  chiefly  an  ammo- 
niacal  solution  of  carmine,  which  stains  the  grey  matter 
more  deeply  than  the  white,  and  in  the  white  matter  only 
the  connective  tissue,  and  not  the  nerve-tubes.  A  pink 
coloration  of  the  white  columns  of  the  cord  therefore  shows, 
even  to  the  naked  eye,  the  presence  of  sclerosis,  the  tint 
being  deeper  in  proportion  to  the  intensity  of  the  degenera- 
tive changes.  Other  useful  staining  fluids  are  Ranvier's 
solution  of  picro-carmine,  and  the  compound  dyes  of  picro- 
aniline,  haematoxyline  with  aniline,  picro-carmine  with 
iodine  green,  nigrosine,  fuchsine,  and  eocine. 

However  valuable  these  several  methods  of  hardening 
and  staining  the  cord  are,  we  must  yet  not  lose  sight  of  the 
fact  that  they  involve  a  great  expenditure  of  time,  are  often 
unsatisfactory  in  the  hands  of  less  practised  observers,  and 
modify  the  structure  of  the  parts  considerably  by  corruga- 
tion. In  order  to  avoid  these  drawbacks,  histologists  have 
for  some  time  past  resorted  to  freezing  the  fresh  structures, 
thereby  avoiding  any  chemical  alteration.  For  some  years 
the  ice-and-salt  freezing  microtome,  as  perfected  by  Ruther- 
ford and  Williams,  was  the  one  principally  employed  ;  but 
this  process  is  objectionable,  inasmuch  as  the  degree  of 
freezing  cannot  be  well  regulated.     Excessive  refrigeration 


MORBID  ANATOMY  OF  TABES  SPINALIS.  17 

causes  the  crystals  of  ice  which  are  formed  to  break  up 
the  delicate  nervous  tissue,  and  therefore  spoils  it  some- 
what for  examination.  The  ether-freezing  microtome,  as 
introduced  by  Bevan  Lewis,^  therefore  constitutes  a  real 
progress.  In  the  construction  of  this  instrument,  Richard- 
son's spray-producer  has  been  ingeniously  utilised,  with 
the  result  that  the  freezing  can  be  checked  at  any  stage, 
and  rene  wedwhen  required.  The  structures,  therefore,  do 
not  assume  that  hard  icy  consistence  which  blunts  or  turns 
the  edge  of  the  blade,  but  may  be  made  to  acquire  just 
such  a  degree  of  density  as  is  best  suitable  for  section- 
cutting. 

Another  process,  which  is  chiefly  suitable  for  examining 
the  ganglionic  cells  of  the  grey  matter  of  the  cord  in  the 
fresh  state,  is  that  known  as  dissociation,  which  was  first 
systematically  practised  by  Gerlach,  and  afterwards  per- 
fected by  Bevan  Lewis.  In  the  latter  method,  sections 
are  placed  in  Miiller's  fluid  for  a  few  minutes,  and  then 
gradually  compressed  by  a  mounted  needle  between  cover- 
glass  and  slide,  when  the  large  ganglionic  cells  will  easily 
come  in  view. 

With  all  these  different  methods  of  microscopic  examina- 
tion at  our  disposal,  however,  it  must  be  confessed  that, 
although  we  may,  and  undoubtedly  do,  gain  a  thorough 
insight  into  the  localisation  of  the  morbid  processes,  the 
more  minute  alterations  of  the  nervous  matter  which  take 
place  in  disease  still  escape  inquiry  to  some  extent,  as  the 
very  means  used  for  examining  the  structures  produce  a 
mechanical  or  chemical  alteration  of  the  diseased  parts,  and 
thus  add  an  artificial  element  which  it  has  hitherto  been 
impossible  to  eliminate. 

In  advanced  stages  of  tabes,  the  microscopic  examination 
of  the  parts  shows  that  the  medullary  sheath  as  well  as  the 
axis-cylinder  of  the  nerve-tubes  constituting  the  posterior 

'  •'  The  Human  Brain,"  p.  92.    London,  1882. 
C 


18  SCLEROSIS  OF  THE  SPINAL  COED. 

columns  have  disappeared.  Their  place  is  taken  by  a 
loose  areolar  tissue,  the  meshes  of  which  contain  fluid 
during  life,  and,  after  staining,  the  different  substances 
used  for  that  purpose.  A  few  healthy  nerve-fibres  are 
generally  found  lying  scattered  about  in  this  tissue,  while 
others  may  be  seen  in  various  stages  of  degeneration. 
They  appear  granular,  varicose,  and  narrower  than  in 
health.  Various  degrees  of  hyperplasia  and  fibrillary 
metamorphosis  of  the  connective  tissue  which  cements 
the  central  nerve-fibres  are  almost  invariably  present. 
Only  few  cells  and  nuclei  are  found  in  the  overgrown 
neuroglia,  which  is  accounted  for  by  the  slow  progress  of 
the  morbid  alteration,  the  cells  thus  growing  old  and 
becoming  gradually  transformed  into  a  firm  fibrillary 
tissue  ;  but  numerous  amyloid  bodies  are  interspersed  in 
the  mass. 

The  arterioles  of  the  posterior  columns  are  likewise 
found  to  have  undergone  a  marked  change.  The  adven- 
titia  is  thickened  and  studded  with  oil-globules  and  granular 
pigmentary  corpuscles.  These  latter  formations  are  also 
seen  in  the  lymphatic  spaces  between  the  external  and 
middle  tunic,  and  even  in  the  tiniest  capillaries,  whose 
coats  are  reduced  to  endothelium.  The  arterioles  appear 
as  whitish  lines  on  the  grey  groundwork  of  the  wasted 
columns,  proceeding  in  a  longitudinal  direction.  Innu- 
merable amyloid  bodies  are  met  with  along  the  course  of 
the  arterioles ;  and  these  are  chiefly  seen  where  the 
degeneration  is  not  very  far  advanced,  while  they  are 
less  abundant  after  the  nervous  matter  has  been  entirely 
destroyed. 

What  region  of  the  posterior  columns  is  first  affected? 
In  general  the  change  appears  to  commence,  and  is  cer- 
tainly most  marked,  in  the  lower  dorsal  and  upper  lumbar 
portion  of  the  cord,  while  the  lower  lumbar  and  cervical 
portions  are  less  affected.  Yet,  even  in  recent  cases,  the 
cord  appears  to  be  generally  affected  in  its  entire  extent, 


MORBID  ANATOMY  OF  TABES  SPINALIS. 


19 


from  the  medulla  oblongata  downwards.  In  cases  of  long 
standing  the  entire  transverse  section  of  the  posterior 
columns,  including  l)Oth  Goll's  and  Burdach's  columns, 
is  sclerosed,  while  in  the  earlier  stages  of  the  disease  the 
process  is  more  strictly  localised  in  certain  areas. 


Section  of  cord  in  wliich  Burdach's  columns  (B)  are  sclerosed 

and  GoU's  columns  ((?)  healthy. 

Pierret,  who  was  the  first  to  examine  this  point  more 
minutely,  concluded  from  his  observations  that  the  disease 
commenced  with  two  symmetrical  islands  of  degeneration 
in  Burdach's  columns,  while  Goll's  columns  only  became 
affected  at  a  subsequent  stage  of  the  malady  with  a  kind 
of  secondary  degeneration.  This  view  was  endorsed  by 
Charcot  and  Vulpian,  and  was  for  some  time  unreservedly 


Section  of  cord  in  which  Burdach's  columns  (B)  and  the  external 
portion  of  Goll's  columns  {G)  are  sclerosed. 

accepted  by  the  profession ;  but  more  recently  Strlimpell,^ 
of  Leipzig,  has  again  carefully  examined  this  point,  and 

'  "  Archiv  fur  Psychiatrie,"  p.  749.     Berlin,  1883. 
c2 


20  SCLEROSIS  OF  THE  SPINAL  CORD. 

has  arrived  at  some  novel  results  of  importance,  whereby 
Pierret's  conclusions  have  been  considerably  modified. 


Fig.  6. 

Schematic  diagram  of  the  different  areas  of  degeneration  in  the 
posterior  columns,  after  Striimpell.  1.  Small  portion  of  diseased  tissue 
at  each  side  of  the  posterior  commissure.  2.  The  bulk  of  Goll's  columns 
converging  anteriorly  in  wedge-shaped  fashion.  3.  Antero-lateral  area 
of  Burdach's  columns,  with  point  directed  backwards.  4.  Small  round 
field  at  the  anterior  broad  extremity  of  the  lateral  anterior  area,  and 
sharply  separated  from  the  apex  of  Goll's  columns.  5.  Postero-external 
field,  with  point  directed  forwards.  6.  Small  band  of  tissue  at  inner 
side  of  posterior  roots. 

According  to  Striimpell,  appearances  differ  in  the  early- 
stages  of  tabes  in  the  different  portions  of  the  cord.  In 
its  dorsal  portion,  two  small  antero-lateral  areas  (Fig.  6, 
No.  3)  are  first  affected,  and  this  is  the  part  from  where 
fibres  proceed  to  the  posterior  cornua  ;  but  almost  at  the 
same  time  a  similar  degeneration  appears  in  a  small  median 
zone  along  the  posterior  fissure  (Fig.  6,  No.  1)  at  the 
innermost  portion  of  Goll's  columns.  Further  on  in  the 
course  of  the  disease  the  bulk  of  Goll's  columns  (Fig.  6, 
No.  2)  begin  to  suffer,  and  their  posterior  portions  more 
than  their  anterior  ones.  The  postero-external  field  of 
Burdach's  columns  (Fig.  6,  No.  5)  remains  normal  for  a 
long  time  ;  but  in  advanced  cases  the  entire  mass  of  the 
posterior  columns  is  found  affected. 

In  the  lumbar  portion  of  the   cord,  the  disease  com- 


MORBID  ANATOMY  OF  TABES  SPINALIS.  21 

mences  in  the  middle  area  of  the  posterior  root-zone,  while 
its  anterior  and  posterior  part  remain  healthy  for  a  long 
time.  Later  on  the  posterior  area  degenerates  likewise, 
and  only  a  small  field  near  the  posterior  fissure  remains 
spared.  The  anterior  zone  remains  much  longer  normal, 
and  appears  in  cases  of  typical  tabes  to  escape  alto- 
gether. 

In  the  cervical  cord  there  are  two  small  lateral  areas  of 
degeneration  (Fig.  6,  No.  4),  which  are  broader  anteriorly. 
Ooll's  columns  appear  to  be  affected  in  the  beginning. 
After  a  time  the  posterior  root-zone  becomes  affected,  but 
the  antero-lateral  section  (Fig.  6,  No.  3)  and  the  postero- 
external field  (Fig.  6,  No.  5)  resist  the  inroads  of  the 
■disease  for  a  considerable  time. 

According  to  these  researches,  therefore,  matters  appear 
to  be  even  more  complicated  than  they  seemed  previously. 
Goll's  columns  are  shown  to  consist  of  three  separate 
divisions,  viz.,  first,  of  a  thin  strand  of  fibres  which  are 
most  interiorly  situated,  close  to  the  sides  of  the  posterior 
fissure,  and  which  are  shown  to  have  a  special  position 
in  the  system  by  degenerating  independently  at  an 
early  stage  of  the  disease  ;  secondly,  of  the  real  bulk  of 
Goll's  columns,  which  are  wedge-shaped  and  pointed 
anteriorly  ;  and,  thirdly,  of  the  small  round  anterior  field 
(Fig.  6,  No.  4),  which  appears  to  be  sharply  separated 
from  the  contiguous  apex  of  G-oll's  columns. 

3.  The  posterior  nerve-roots  are  generally  found  wasted, 
and  in  old  cases  so  much  so  that  it  may  be  difficult  to  dis- 
cover them,  more  especially  in  the  dorso-lumbar  portion  of 
the  cord,  where  in  general  the  change  is  greatest.  They  show 
a  grey,  reddish  or  black  discoloration,  and  form  a  striking 
contrast  to  the  anterior  roots,  which  remain  white,  large, 
and  plump.  On  examining  the  posterior  roots,  it  appears 
that  the  nerve-fibres  are  destroyed,  having  undergone 
granular  and  fatty  degeneration  ;  and  this  destructive 
process  invades  more  particularly  the  axis-cylinder,  while 


22  SCLEROSIS  OF  THE  SPINAL  CORD. 

the  medullary  sheath  resists  much  longer,  and  may  still 
be  seen  after  everything  else  is  gone.  If  nerve-fibres  are 
still  met  with  in  advanced  cases,  their  diameter  is  greatly 
reduced. 

4.  The  spinal  ganglia  show,  as  a  rule,  no  alteration  what- 
ever, not  even  those  which  correspond  in  anatomical  position 
to  the  most  severely  affected  areas  of  the  posterior  roots 
and  columns.  Vulpian  has  found  these  structures  some- 
times perhaps  a  little  more  pigmented  than  usual ;  yet 
it  should  be  considered  that  healthy  cells  often  contain 
a  good  deal  of  pigment.  In  general  the  nucleus  and 
nucleolus  of  the  cell  does  not  appear  to  be  altered. 
Luys  and|Pierret  have  in  a  few  cases  seen  some  amount 
of  wasting  in  these  ganglionic  masses,  but  this  is  cer- 
tainly a  very  exceptional  occurrence.  In  connexion  with 
this  point  it  should  not  be  forgotten  that  our  means  for 
ascertaining  the  exact  condition  of  ganglionic  cells  are 
still  defective,  and  that  it  is  most  difficult  to  demonstrate 
satisfactorily  that  there  is  any  real  atrophy  in  these  struc- 
tures. 

5.  The  central  grey  matter  of  the  cord,  on  the  other  hand, 
appears  not  unfrequently  to  participate  more  or  less  in  the 
disease.  It  is  more  especially  the  posterior  cornua,  and 
the  place  of  junction  between  the  anterior  and  posterior 
cornua,  and  Clarke's  vesicular  columns,  which  are  often 
found  affected.  The  sclerosis,  however,  appears  to  invade 
more  the  nerve-tubes  and  the  neuroglia  than  the  ganglionic 
cells,  and  there  can  be  little  doubt  that  the  same  fibres  which 
become  destroyed  in  the  posterior  columns,  waste  in  their 
further  course  in  the  grey  matter.  Where,  therefore,  the 
posterior  cornua  are  found  reduced  in  size,  this  is  owing  to 
atrophy,  not  of  cells,  but  of  fibres.  The  anterior  cornua, 
with  their  giant  cells,  have  mostly  been  found  healthy; 
yet  Leydeni  has  recently  drawn  attention  to  a   peculiar 

*  **  Tabes  Dorsalis,"  p.  15.    Vienna,  1883. 


MORBID  ANATOMY  OF  TABES  SPINALIS.  23 

condition  of  these  cells,  more  especially  in  the  lumbar  en- 
largement of  the  cord,  which  appears  to  be  by  no  means 
mif reqnent.  There  is  no  actual  wasting  in  them ;  but  thej 
appear  strongly  pigmented,  tough,  harder  and  rounder  than 
usual,  more  or  less  reduced  in  size;  and  their  processes  are 
small,  tough,  and  fragile.  It  seems  not  unlikely  that  this 
may  be  the  anatomical  substratum  of  the  flabby,  weakened, 
and  ill-nourished  condition  which  is  habitually  found  in 
the  muscles  of  tabid  patients,  more  especially  in  the  ad- 
vanced stages  of  the  disease.  This  is,  however,  entirely 
different  from  actual  wasting  of  the  muscular  fibre,  which 
also  occurs  not  unfrequently  in  tabes.  I  have  notes  of  a 
somewhat  considerable  number  of  cases  in  which  sometimes 
early,  sometimes  late,  the  well-known  clinical  signs  of 
muscular  atrophy — i.e.,  destructive  wasting  of  fibres,  with 
fibrillary  twitches  in  the  affected  muscles — were  added  to 
the  symptoms  of  tabes. 

There  can  be  no  doubt  that  this  is  not  a  simple  coinci- 
dence, but  that  there  exists  a  peculiar  connection  between 
sclerosis    of  the   posterior   columns    and   atrophy   of  the 
anterior  cornua.    The  muscular  atrophy  observed  in  tabid 
patients  has  not   the  well-known  distribution  of  progres- 
sive muscular  atrophy,  or  of  lead-palsy.    It  is  in  general 
limited  tp  certain  regions,  for   instance  the  hand,    where 
it  affects  the  balls  of  the  thumb  and  the  little  finger,  as  well 
as  the  interosseous  muscles;  or  it  may  affect  the  foot,  certain 
portions  of  the  back   and   the   neck,    and,   after  existing 
for  some  time  in  one  side,  it  will  eventually  attack  the  sym- 
metrical portion  of  the  other  side.     I  have  at  the  present 
time  a  patient  under  my  care  in  whom  the  symptoms   of 
tabes  have  affected  principally,  although  not  exclusively, 
the   left    side  of  the  body,    and   where   there   is  marked 
wasting  of  all  the  muscles  of  the  left  hand.     The  muscles 
of  the  forearm,  arm,  and  shoulder  do  not  show  the  slightest 
signs  of  atrophy.     On  the  other  hand,  fibrillary  twitches 
have  just  commenced  to  occur  in  the  interosseous  muscles 


24  SCLEROSIS  OF  THE  SPINAL  CORD. 

of  the  right  hand,  with  a  corresponding  amount  of  debility, 
showing  that  the  affection  is  beginning  to  invade  the 
symmetrical  portion  of  the  other  side. 

Cases  of  this  kind  have  but  rarely  come  on  the  post- 
mortem table;  but  Pierret  ^  has  recorded  one  in  which  there 
had  been  well-marked  wasting  of  the  muscles  of  the  right 
side  of  the  body  during  life,  and  where  after  death  the 
entire  anterior  horn  of  the  right  side  of  the  cord  was  found 
to  be  wasted,  while  the  left  anterior  horn  had  remained 
normal.  The  diameter  of  the  right  horn  was  much  less  in 
the  cervical  portion  than  that  of  the  left;  groups  of  myelo- 
cytes were  seen  close  to  the  giant  cells;  the  latter  showed 
a  large  accumulation  of  pigment  and  commencement  of 
atrophy.  In  the  cord,  Clarke's  vesicular  columns  showed 
considerable  alterations;  some  of  their  cells  had  entirely 
disappeared,  others  were  evidently  diseased  and  were 
only  represented  by  small  heaps  of  brown  granulations. 
The  right  anterior  horn  had  only  about  half  the  dimension 
of  the  left,  and  some  of  its  cells  had  undergone  diverse 
degrees  of  pigmentary  atrophy.  In  the  lumbar  region  this 
lesion  was  much  more  marked.  Some  of  the  giant  cells 
had  here  completely  disappeared,  and  their  place  was 
taken  by  a  finely  granular  fibrous  tissue  containing 
oil-globules  and  amyloid  bodies.  The  shrinking  of  this 
tissue  had  no  doubt  to  a  great  extent  caused  the  diminu- 
tion in  the  diameter  of  the  right  anterior  horn.  To  this 
corresponded  certain  appearances  in  the  affected  muscles  of 
the  limbs  and  body,  likewise  on  the  right  side.  They  were 
pale  and  thin;  there  were  a  few  primitive  bundles  affected 
with  granular  degeneration,  while  there  were  numerous 
bundles  which  showed  simple  atrophy,  yet  had  preserved 
their  transverse  stripes.  The  nuclei  of  the  sarcolemma 
were  greatly  proliferated,  causing  some  of  these  bundles 
actually  to  be  distended  by  them.     These  changes  corre- 

^  **  Archives  de  Physiologie,"  p.  599.    Paris,  1871. 


MORBID  ANATOMY  OF  TABES  SPINALIS.  25 

sponded  in  degree  exactly  to  the  changes  in  the  anterior 
horns,  being  more  marked  in  the  muscles  of  the  lower 
extremity  than  in  those  of  the  body  and  the  upper  limb. 

Bevan  Lewis^  has  lately  described  a  case  of  tabes,  in 
which  the  posterior  columns  appeared  to  be  almost  de- 
stroyed in  the  dorsal  portion  of  the  cord;  and  where  in  those 
regions  which  were  stamped  by  the  greatest  intensity  of 
morbid  change,  the  anterior  cornua  had  invariably  suffered, 
the  various  groups  of  cells  being  either  greatly  wasted  or 
wholly  absent;  and  the  hemispheric  distribution  of  the 
lesion  was  such  that,  whilst  one  horn  might  be  entirely 
free  from  disease,  the  opposite  one  might  be  found 
shrunken  to  one-half  its  proper  dimensions.  This  atrophy 
was  most  apparent  in  the  central  and  lateral  groups  of  the 
cells.  In  that  case  the  direct  cerebellar  column  was  also 
involved,  while  the  crossed  pyramidal,  and  Tiirck's  columns 
were  perfectly  healthy.  The  anterior  root-zone,  however, 
showed  a  morbid  change  limited  to  one  hemisphere,  and 
probably  consequent  upon  changes  in  the  corresponding 
cornu.  Singularly  enough,  no  muscular  atrophy  is  men- 
tioned as  having  existed  during  life  in  the  clinical 
history  of  the  case,  but  this  may  possibly  have  been 
overlooked. 

6.  The  lateral  columns  of  the  cord  are  found  to  be 
normal  in  the  earlier  stages  of  the  disease,  but  may  become 
affected  later  on.  It  might  be  assumed  that  this  arose 
from  a  simple  spreading  of  the  degeneration  in  loco,  and 
in  a  transverse  direction,  as  in  myelitis;  but  it  is  more 
probably  an  independent  system-disease,  which  becomes 
complicated  with  tabes  in  its  more  advanced  stages.  This 
view  seems  to  me  the  more  probable  one,  more  especially 
as  we  find  that  the  lateral  column  is  not  diseased  in  toto, 
but  that  chiefly  that  portion  of  it  is  affected  which  is 
known    as   Flechsig's   direct    cerebellar   column.     In   ex- 

'  "Brain,"  January,  1884. 


26  SCLEROSIS  OF  THE  SPINAL  CORD. 

ceptional  cases,  however,  the  affection  has  been  seen  to 
spread  as  far  as  the  anterior  columns. 

7.  The  sympathetic  system  of  nerves  appears  to  be  gener- 
ally unaltered.  In  a  few  cases,  however,  wasting  of  the 
myeline-sheaths  and  of  the  nerve-cells  of  the  sympathetic 
ganglia  has  been  noticed.  Recent  observations  to  this 
effect  have  been  made,  under  the  superintendence  of 
Vulpian,  by  Raymond  and  Arthaud,  who  found  prolifera- 
tion of  connective  tissue,  thickening  of  blood-vessels, 
atrophy  of  ganglionic  cells,  oil-globules  with  colouring 
matter,  and  fatty  degeneration  of  the  nuclei  of  Remak's 
fibres. 

8.  In  the  brain  there  may  be  no  change  whatever.  As  a 
rule  the  affection  does  not  extend  beyond  the  bulb,  where 
the  nuclei  of  the  fifth  and  auditory  nerves  are  occasion- 
ally seen  sclerosed.  Where,  however,  tabes  ultimately 
becomes  complicated  with  epilepsy,  general  paralysis  of 
the  insane,  and  other  analogous  conditions,  diffuse  changes 
in  the  cortex  and  the  pia  mater  of  the  brain  have  been 
discovered. 

9.  The  cranial  nerves  are  not  unfrequently  found  affected. 
The  olfactory  nerve  is  liable  to  atrophy;  and  its  sheath  may 
be  filled  up  with  amyloid  bodies.  This  wasting  appears  to 
affect  chiefly  the  external  root,  which  may  be  traced  to  the 
fissure  of  Sylvius,  and  which  is  more  important  for  olfac- 
tion than  the  middle  or  internal  root  of  the  nerve.  Some 
time  ago  a  patient  was  under  my  care  at  the  hospital,  in 
whom  there  had  been  symptoms  of  acute  olfactory  neuritis 
followed  by  complete  anosmia  in  the  initial  stage  of  tabes, 
and  who  died  of  sudden  collapse  eight  years  afterwards. 
Wasting  of  the  first  pair  of  nerves  at  the  base  of  the  brain 
was  discovered  2'>ost  mortem. 

The  optic  nerve  suffers  habitually  in  tabes,  and  often 
quite  in  the  beginning  of  the  malady.  It  has  been  found 
reduced  to  one-half  or  even  one-third  of  its  ordinary 
diameter,  and  shows  to  the  naked  eye  the  same  state  of 


MORBID  ANATOMY  OF  TABES  SPINALIS.  27 

grey  induration  as  is  seen  in  the  posterior  columns  of  the 
cord.  The  axis-cjlinder  and  medullary  sheath  are  wasted, 
and  a  tough  mass  of  overgrown  neuroglia  is  left,  with 
which  is  mixed  amorphous  matter,  some  oil-globules,  and 
amyloid  bodies.  Occasionally  a  few  healthy  nerve-fibres 
may  be  left.  The  papilla  of  the  nerve  is  whiter  and  more 
depressed  than  in  health,  and  the  arterioles  are  less  visible. 
The  disease  is  generally  believed  to  begin  in  the  peri- 
pheral end  of  the  nerve,  and  from  there  to  creep  further 
on  to  the  centre.  If  both  nerves  are  affected,  the  wasting 
is  found  to  extend  backwards  to  the  chiasma,  the  optic 
tracts,  and  the  corpora  geniculata.  When  only  one  nerve 
is  diseased,  the  chiasma  loses  its  shape,  and  of  the  two 
optic  tracts  the  one  opposite  to  the  diseased  nerve  is 
sclerosed,  while  the  one  on  the  same  side  is  healthy, 
showing  that  there  is  crossing  of  fibres  in  the  chiasma. 

While,  therefore,  until  now  it  has  been  generally  held 
that  optic  atrophy  begins  in  the  peripheral  expansion  of 
the  nerve,  Poucet  has  lately  come  to  the  conclusion  that 
the  alteration  is  more  central  than  peripheral.  He  ex- 
amined a  case  of  tabes  where  the  patient  had  been  blind 
for  ten  years,  and  discovered  sclerosis  of  the  optic  nerve  in 
its  orbital  portion,  and  atrophy  without  sclerosis  in  its 
cerebral  portion.  In  the  retina,  there  was  destruction  of 
the  proper  fibres  of  the  optic  nerve  and  the  ganglionic 
cells,  while  the  internal  and  external  granular  layer  (the 
latter  identical  with  Ranvier's  "visual  cells")  was  healthy. 
In  the  region  of  the  macula,  the  cones  were  healthy. 
Poucet  therefore  considers  that  in  the  blindness  of  tabes 
the  alteration  is  not  peripheral,  but  central;  that  the 
sclerosis  of  the  orbital  portion  of  the  optic  nerve  is 
secondary  to  the  parenchymatous  atrophy,  and  that  the 
tissue  and  cells  of  the  neuroglia  show  no  overgrowth. 
Further  observations  on  this  point  are  highly  desirable. 

The  third  nerve  has  been  found  wasted,  either  in  its 
entirety  or  in  some  of  its  branches  ;  and  I  have  seen  the 


28  SCLEROSIS  OF  THE  SPINAL  CORD. 

same  condition  in  the  sixth  nerve  in  a  case  where  the  patient 
had  suffered  from  persistent  paralysis  of  the  external  rectus 
muscle. 

The  nuclei  of  the  ffth  and  auditory  nerves  have  been 
found  wasted  by  Hayem  and  Pierret  ;  but  whether  these 
nerves  suffer  in  their  peripheral  course  is  as  yet  uncertain. 
As  they  draw  their  trophic  influence  not  only  from  their 
nuclei  in  the  medulla  oblongata,  but  also  from  ganglionic 
cells  with  which  they  communicate  further  in  front,  it  does 
not  absolutely  follow  that  sclerosis  of  their  nuclei  must 
needs  entail  wasting  of  the  peripheral  expansions  of  the 
nerves.  Some  time  ago  I  had  a  case  under  my  care  at  the 
hospital  in  which  a  patient  suffering  from  tabes  had  become 
completely  deaf  in  consequence  of  what  appeared  to  have 
been  an  attack  of  acute  double  auditory  neuritis.  The 
patient  recovered  from  all  symptoms  of  tabes,  but  remained 
stone-deaf  ;  and  were  it  to  come  to  an  inspection,  I  have  no 
doubt  that  complete  atrophy  of  both  auditory  nerves  would 
be  discovered  in  that  case. 

It  will  be  important,  in  future  investigations  of  this  kind, 
to  keep  in  mind  that  the  auditory  nerve  has  been  physio- 
logically and  histologically  proved  to  be  a  compound  nerve, 
and  to  consist  of  two  different  portions,  one  of  which  is  the 
nerve  of  the  special  sense  of  hearing,  while  the  other  is  the 
nerve  of  the  sense  of  space,  and  supplies  the  semicircular 
canals,  which  are  the  peripheral  organs  of  the  sense  of 
space.  During  their  transit  through  the  internal  auditory 
meatus,  these  two  nerves  are  perfectly  distinct,  owing  to  a 
well-developed  strand  of  connective  tissue  between  them. 
The  finer  histology  of  these  nerves  has  recently  been  studied 
by  Erlitzky,  Axel  Key,  and  Ketzius.  According  to  these 
observers,  the  nerve  consists  of  a  larger  anterior  and 
inferior,  and  a  smaller  posterior  and  superior  portion. 
These  two  portions  are  distinguished  by  the  characters  of 
the  nerve-tubes  composing  them.  In  the  former  portion 
dissociation  shows  delicate  fibres,  whose  axis-cylinders  are 


MORBID  ANATOMY  OF  TABES  SPINALIS.  29 

only  slightly  coloured  by  carmine,  and  which  are  covered  by 
a  very  slight  circular  layer  of  myeline ;  there  are  no  nuclei 
in  Schwann's  sheath,  nor  annular  constrictions  ;  the  fibres 
show  frequent  enlargements  all  along  their  course,  probably 
owing  to  the  axis-cylinders  and  their  sheaths,  while  the 
layer  of  myeline  shows  the  same  thickness  in  the  enlarge- 
ments as  in  the  intermediate  portions.  This  is  the  cochleary 
or  true  auditory  nerve.  The  second  portion  contains  much 
thicker  fibres,  which  are  well  coloured  by  carmine,  and 
show  annular  constrictions.  They  resemble  the  other 
nerves,  and  constitute  the  vestibulary  nerve,  or  the  nerve  of 
space.  Of  these  two  portions  of  the  nerve,  the  space- 
fibres  appear  to  suffer  much  more  frequently  in  tabes  than 
the  auditory  fibres,  more  especially  in  the  earlier  stages  of 
the  malady,  and  should,  therefore,  be  examined  with  par- 
ticular care. 

The  nuclei  of  the  glosso-pharyngeal  and  vago-accessory 
nerves  have  likewise  been  found  sclerosed.  The  roots  of 
these  nerves  form,  together  with  sympathetic  fibres,  a  kind 
of  intermediary  system  with  motor  and  sensory  zones.  This 
corresponds  to  Stilling's  "  solitary  strand,"  and  to  Clarke's 
*'  slender  column,"  gives  off  the  intermediate  nerve  of  Wris- 
berg,  which  is  vasomotor,  and  is  connected  with  motor  and 
sensory  ganglia.  This  strand  proceeds  at  the  level  of  the 
decussation  of  the  pyramids  towards  the  side  of  the  spinal 
accessory  nerve,  and  is  found  in  the  upper  portion  of  the 
cord  in  the  intermedio-lateral  tract,  whence  sympathetic 
fibres  take  their  origin.  Pierret  believes  that  sclerosis  of 
this  tract  is  the  cause  of  the  gastric  crises  and  other  vaso- 
motor and  visceral  troubles  which  occur  in  tabes.  Kahler 
has  quite  recently  described  a  case  in  which  there  had  been 
pharyngeal  paralysis,  aphonia  from  loss  of  power  in  the 
right  vocal  cord,  fits  of  spasmodic  cough,  and  gastric  crises. 
At  the  necropsy,  the  oblongata  was  found  healthy,  with  the 
exception  of  sub-ependymal  sclerosis,  which  penetrated 
into  the  grey  matter  on   the  floor  of  the  fourth  ventricle, 


30  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  involved  the  nuclei  of  the  vago-accessory  nerves,  more 
especially  the  one  on  the  right  side. 

10,  The  spinal  nerves  and  their  terminations  in  the  skin, 
the  joints,  the  muscles,  etc.,  have  generally  been  believed 
to  remain  healthy  in  tabes.  In  his  latest  essay  on  the 
disease,  in  Eulen burg's  "  Encyclopadie  der  medicinischen 
Wissenschaften "  (Vienna,  1883),  Leyden  says,  that  no 
alterations  in  these  nerves  have  been  discovered.  Yet 
there  can  be  little  doubt  that  disease  of  these  parts  has 
been  frequently  overlooked,  partly  from  preconceived  ideas 
about  the  nature  of  the  malady,  and  partly  because  to  the 
naked  eye  these  nerves  may  appear  perfectly  healthy, 
showing  neither  softening  nor  induration,  cedema,  or  any 
other  change.  Yet  it  had  often  struck  observers,  in 
examining  cases  of  tabes  clinically  and  anatomically,  that 
there  w^as  no  apparent  relation  between  the  symptoms 
in  the  sphere  of  sensibility  observed  during  life  and  the 
lesions  found  in  the  posterior  columns  and  nerve-roots  after 
death.  This  naturally  led  to  the  supposition  that  there 
might  be,  apart  from  the  central  lesion,  likewise  a  peri- 
pheral one  in  the  cutaneous  nerves. 

Langenbuch,  when  proposing  the  operation  of  nerve- 
stretching  for  the  relief  or  cure  of  tabes,  described  certain 
gross  lesions  which  he  had  perceived  in  the  large  nerves 
of  the  extremities  after  they  had  been  laid  bare  for  the 
purpose  of  operation.  Subsequent  writers,  however,  stated 
that  such  lesions  did  not  exist,  but  had  been  found 
necessary  in  order  to  render  the  wonderful  effects  of  nerve- 
stretching  more  intelligible  !^  Such  a  state  of  opinion  makes 
it  incumbent  upon  us  to  consider  this  question  somewhat 
more  in  detail  than  we  should  otherwise  have  considered 
necessary. 

Tiirck,  of  Vienna,  who  was  the  first  to  describe  secondary 
sclerosis  of  the  lateral  columns  of  the  cord,  consequent  upon 
cerebral  haemorrhage,  and  whose  keen  insight  into  the 
morbid  anatomy  of  the  nervous  centres  altogether  was  very 


MORBID  ANATOMY  OF  TABES  SPINALIS.  31 

much  in  advance  of  his  time,  took  up  this  inquiry  as  far 
back  as  1858,  but  was  led  to  negative  results,  as  was  also 
Yulpian  in  1868.  Westphal  was  the  first  to  discover,  ten 
years  later,  atrophy  of  the  cutaneous  branches  of  the  crural 
nerve  in  a  case  of  combined  posterior  and  lateral  sclerosis. 
Pierret  afterwards  expressed  his  belief  that  the  lightning 
pains,  the  anaesthesia,  and  certain  trophic  disturbances  in 
tabes  depended  upon  a  form  of  peripheral  neuritis  analogous 
to  optic  neuritis,  which  was  seen  in  the  terminal  expansions 
of  the  cutaneous  nerves,  became  less  marked  further  away 
from  the  periphery,  but  was  again  discovered  in  the 
central  ends  of  the  afiected  nerves. 

Pitres  and  Yaillard^  have  recently  made  a  very  able 
inquiry  into  this  point,  and  found  that  in  certain  cases  of 
tabes  histological  alterations  occur  in  the  peripheral 
branches  of  the  spinal  nerves  resembling  very  closely 
those  which  are  known  as  Wallerian  degeneration,  viz., 
such  as  occur  after  experimental  section  in  the  divided 
nerve.  In  the  beginning  there  is  a  swelling  of  the  nucleus 
of  the  fibres  and  segmentation  of  myeline;  and  eventually 
complete  destruction  of  the  axis-cylinder  and  the  medul- 
lary sheath  takes  place.  This  form  of  neuritis  has,  how- 
ever, not  the  uniform  course  of  Wallerian  degeneration, 
but  is  sometimes  slow  and  at  other  times  exceedingly 
rapid  in  its  progress.  The  ordinary  Wallerian  degeneration 
follows  a  regular  evolution,  the  phases  of  which  take  place 
at  perfectly  definite  intervals,  and  with  a  kind  of  mathe- 
matical certainty  which  has  been  determined  by  experi- 
ment, and  which  can  be  exactly  foreseen.  The  form  of 
neuritis,  however,  which  occurs  in  tabes  has  no  such 
regular  course.  It  may  moreover  spread  from  the  peri- 
phery to  the  centre,  which  never  occurs  in  Wallerian 
degeneration.  The  inflammation  appears  to  affect  only 
the   nerves,    and   not   the  intertubular  connective   tissue. 

1  ''Archives  de  Neurologie,"  Paris,  1883  (March  to  September). 


32  SCLEROSIS  OF  THE  SPINAL  CORD. 

The  latter  only  appears  to  overgrow  after  the  neuritis  has 
already  destroyed  the  nerve-tubes.  The  course  of  the 
neuritis  may  either  be  very  rapid  or  slow;  and  while  there 
is  an  ascending  centripetal  tendency,  yet  there  does  not 
appear  to  be  any  continuous  alteration  between  the  cord 
and  the  altered  nerves,  the  nerve-trunks  having  generally 
been  found  healthy. 

Pitres  and  Vaillard  have  described  five  different  types 
of  inflammation,  viz.,  fragmentation  of  myeline  (1)  into 
shafts,  (2)  globules,  (3)  granulations,  the  latter  giving  the 
nerve-fibre  a  varicose  aspect;  (4)  atrophy  of  tubes  with 
yellow  granulations  in  the  interior  of  the  sheaths;  and 
finally  (5)  complete  atrophy  with  empty  sheaths.  These 
different  alterations  are,  however,  rarely  found  to  invade 
the  nerve-tubes  in  exactly  the  same  manner,  but  seem  to 
combine  in  a  variety  of  ways.  Thus,  with  fibres  whose 
myeline  has  been  divided  into  voluminous  shafts,  one 
finds  varicose  and  partially  atrophied  fibres;  or  varicose 
tubes  are  mixed  with  atrophied  tubes  containing  only 
yellow  granulations.  In  some  cases  there  were  found,  by 
the  side  of  deeply  degenerated  fibres,  delicate  nerve-tubes 
with  greyish  contours,  such  as  one  meets  with  in  em- 
bryonic rather  than  in  adult  fibres;  and  these  are  probably 
regenerated  fibres,  resembling  those  which  are  seen  at  the 
peripheral  extremity  of  divided'  nerves,  three  or  four 
months  after  their  section.  In  the  intraf  ascicular  connective 
tissue  the  cellular  elements  were  more  numerous,  swollen, 
rounded,  provided  with  a  large  nucleus,  their  protoplasm 
being  filled  with  granulations  varying  in  colour  from  light 
grey  to  deep  yellow. 

It  must  also  be  mentioned  that  these  peripheral  neuri- 
tides  do  not  invariably  give  rise  to  nutritive  or  sensory 
disturbances.  The  latter  only  occur  when  the  proportion 
of  altered  nerve-fibres  is  very  considerable,  and  vary 
according  to  the  extent  of  the  change  and  to  the  special 
functions  of  the  affected  fibres.     Thus  in  one  case  of  tabes. 


MORBID  AKATOMr  OF  TABES  SPINALIS.  33 

Pitres  and  Yaillard  found  that,  while  the  median  and 
musculo-spiral  nerve  were  quite  healthy  at  the  lower  end 
of  the  humerus,  there  was  atrophy  in  the  dorsal  branch  of 
the  musculo-spiral  nerve  at  the  lower  portion  of  the  fore- 
arm, and  in  the  collateral  nerves  of  the  thumb,  first  and 
third  fingers.  The  clinical  symptoms  corresponding  to 
this  were  deformity  of  the  metacarpo-phalangeal  joint  of 
the  first  finger,  the  surfaces  being  swollen  and  it  being 
easy  to  dislocate  the  phalanx  on  the  metacarpal  bone  as 
well  as  to  reduce  the  dislocation  afterwards.  Nothing 
particular,  however,  was  noticed  in  the  thumb  and  first 
finger.  In  the  lower  extremity  there  was  found  atrophy 
of  nerve-tubes,  chiefly  in  the  plantaris  internus,  and  the 
collateral  internal  and  external  nerves  of  the  big  toe;  to 
which  during  life  had  corresponded  perforating  ulcer  in 
the  soles  of  the  feet  and  dystrophy  of  toe-nails.  Further 
signs  were  sclerosis  of  the  posterior  roots  and  columns, 
while  the  intermediate  nerve-trunks  and  the  anterior  roots 
were  perfectly  healthy.  Analogous  changes  were  dis- 
covered in  cases  of  Pott's  disease  and  myelitis,  owing  to 
caries  of  cervical  vertebrae.  In  the  latter  case  there  were 
bedsores  on  the  sacrum  and  heel,  pemphigus,  and  dys- 
trophy of  the  toe-nails. 

It  is  probable  that  the  central  lesion  is  not  the  immediate 
cause  of  the  peripheral  neuritis,  but  only  a  predisposing 
condition,  and  that  other  influences,  such  as  pressure,  etc., 
are  likewise  necessary  for  its  production.  It  is  also 
worthy  of  remark  that  this  form  of  neuritis  is  not  peculiar 
to  tabes,  but  occurs  after  hemiplegia  from  cerebral  soften- 
ing, fracture  of  the  skull,  in  herpes  zoster,  leukaemia,  and 
in  other  conditions  where  the  power  of  the  central  nervous 
system  is  reduced  below  par.  It  causes,  according  to  the 
function  of  the  affected  nerve,  either  severe  symptoms  in 
the  sphere  of  sensibility,  or  various  nutritive  disturbances, 
such  as  vesicular  and  bullous  eruptions,  hard  oedema,  and 
perforating  ulcer,  as  well  as  the  acute  bedsore  which  some- 

D 


54  SCLEROSIS  OF  THE   SPINAL  CORD. 

times  supervenes  in  the  course  of  certain  diseases  of  the 
nervous  centres,  and  is  probably  intimately  connected  with 
the  occurrence  of  Charcot's  joint-disease.  It  has  no  doubt 
been  often  overlooked,  chiefly  because  the  changes  in  the 
nerves  are  not  perceptible  to  the  naked  eye,  but  are  only 
found  after  staining  and  by  microscopic  investigation. 

These  arguments  appear  to  me  to  find  considerable  sup- 
port in  some  recent  observations  of  Dejerine,  who  has 
described  two  cases  in  which  there  had  been  during  life 
very  marked  sensory  disturbances  of  nearly  the  same 
•degree  of  intensity,  but  where  the  inspection  showed  in 
one  case  extensive  disease  of  the  posterior  roots  and 
columns,  and  hardly  any  such  lesion  in  the  other.  On 
examining,  however,  the  nerves  in  the  latter  case,  neuritis 
was  discovered  in  their  peripheral  expansions,  while  their 
more  central  parts,  and  also  the  spinal  ganglia,  which  are 
their  trophic  centres,  were  healthy. 

Pierret  considers  it  probable  that  the  corpuscula  tactus 
in  the  skin  are  primarily  altered,  and  that  the  peripheral 
neuritis  is  a  consequence  of  this  alteration;  but  this  view  is 
contradicted  by  observations  of  Langerhans,  who  examined 
the  corpuscula  tactus  in  six  tabid  patients  in  whom  con- 
siderable alterations  of  cutaneous  sensibility  had  occurred 
•during  life,  and  found  them  perfectly  normal. 

The  alteration  of  cutaneous  nerves  in  tabes  would  there- 
fore appear  to  be  quite  independent  of  their  trophic  centres 
and  terminal  expansions,  and  to  constitute  a  true  peripheral 
-neuritis,  which  is  not  necessarily  related  to  the  medullary 
lesion. 

Until  quite  recently  alterations  of  sensibility  found  to 
exist  in  tabid  patients  have  been  ascribed  to  lesions  of  the 
posterior  columns  and  roots;  and  much  further  research 
will  be  necessary  before  we  can  be  sure  that  peripheral 
neuritis  is  at  all  constant  under  such  circumstances.  There 
•can,  however,  be  no  doubt  that,  when  it  is  discovered,  it 
will  explain  why  cutaneous  symptoms  should  have  been 


MORBID  ANATOMY  OF  TABES  SPINALIS.  35 

promiuent,  while  in  cases  where  it  is  absent  or  slight  such 
signs  might  have  been  wanting.  Neuritis  probably  plays 
an  important  part  in  the  retardation  of  sensation,  and  also 
in  the  diminution  of  faradic  sensibility,  which  is  so  fre- 
quently observed  in  cases  of  tabes. 

11.  Charcot's  ariAropaf^z<9S  finally  claim  our  attention.  It 
is  not  a  little  singular  that  this  condition,  which  is  not 
so  very  rare — for  Charcot  has  seen  it  to  occur  on  the 
average  in  one  out  of  ten  cases  of  tabes — should,  until 
quite  recently,  have  been  overlooked;  and  that  the  creators 
and  custodians  of  the  great  anatomical  museums  in  the 
different  capitals  of  Europe,  such  as  Hunter,  Stanley,  and 
Sir  James  Paget  in  London,  Johannes  Miiller  in  Berlin, 
Dupuytren  in  Paris,  etc.,  should  not  have  preserved  any 
specimens  of  it.  The  idea  has  therefore  been  started  that 
we  have  here  to  do  with  an  entirely  new  disease;  but  it 
appears  to  me  much  more  rational  to  assume  that  these 
lesions  have  been  habitually  confounded  with  those  pro- 
duced by  rheumatic  gout,  and  that  Charcot's  keen  clinical 
instinct,  assisted  by  his  unrivalled  opportunities  of  having 
constantly  hundreds  of  old  women  in  various  stages  of 
spinal  disease  under  his  eyes  at  the  Salpetriere,  succeeded 
in  connecting  certain  joint-lesions  with  the  occurrence  of 
tabes. 

A  benign  and  malignant  form  of  this  affection  is  dis- 
tinguished. In  the  former  there  is  a  sudden  but  painless 
effusion  of  serum,  which  is  gradually  absorbed  and  causes 
no  further  trouble  ;  while  in  the  latter  there  is  rapid  de- 
struction of  a  joint,  and  dislocation  of  the  head  of  the  bone, 
which  becomes  presently  eroded  and  atrophied,  without 
the  formation  of  stalactites  or  the  ordinary  appearances  of 
arthritis  sicca.  If  the  disease  attacks  the  shafts  of  the 
bones,  spontaneous  fracture  may  occur  from  atrophy.  In 
some  cases  indeed  the  fragility  of  bones  appears  so  great 
that  the  most  trivial  causes  seem  to  induce  fracture.  Thus 
a  sudden  movement  of  tlie  leg  has  led  to  fracture   of  the 

D  2 


36  SCLEROSIS  OF  THE  SPINAL  CORD. 

tliigli-bone;  and  in  a  case  recorded  by  Yon  Bruns,  a  patient 
actually  broke  his  j  aw  through  munching  a  lump  of  sugar  ! 
In  one  case,  fractures  occurred  in  six  different  bones. 
A  marked  lesion  in  such  bones  is  a  widening  of  the 
Haversian  canals,  and  great  deficiency  of  phosphate  of 
lime. 

The  pathology  of  arthropathies  and  other  trophic 
changes  supervening  in  the  course  of  tabes,  such  as  spon- 
taneous fracture,  perforating  ulcer,  falling  out  of  nails, 
hard  oedema  of  the  skin,  eruptions,  etc.,  is  still  very 
obscure.  When  Charcot  ^  first  described  them  (1868-70), 
the  connexion  between  the  integrity  of  the  large  gan- 
gUonic  cells  of  the  anterior  cornua  and  the  nutrition  of 
the  muscles  had  just  been  ascertained.  It  was  then 
thought  that  in  cases  of  arthropathy  the  anterior  cornua 
were  at  fault,  and  a  few  observations  seemed  at  first 
to  confirm  this  idea ;  but  soon  afterwards  contradictory 
facts  were  observed,  and  that  theory  has  now  been  given 
up.  Moreover  it  would  be  difficult  to  understand  why 
arthropathies  should  not  be  common  in  infantile  paralysis 
or  progressive  muscular  atrophy,  where  the  anterior  cornua 
are  notoriously  affected.  On  the  other  hand,  the  joint- 
affection  is  not  habitually  connected  with  wasting  of  the 
muscles.  It  seems,  therefore,  much  more  probable  that 
the  arthropathy  is  owing  to  local  changes  in  the  peripheral 
nerves.  The  nerves  of  the  joints  and  the  muscles  may 
undergo  neuritis,  as  seen  by  Pitres  and  Vaillard  in  a 
case  of  tabes,  where  the  left  sciatic  nerve,  as  well  as  the 
left  posterior  articular  nerve  and  the  muscular  nerve  of  the 
same  side  showed  degeneration.  These  changes  corre- 
sponded to  the  following  symptoms  observed  during  life: — 
The  left  lower  extremity  had  been  for  six  months  affected 
by  a  swelling  which  extended  from  the  upper  portion  of 
the  thigh  down  to  the  malleoli;  there  was  also  a  slight 

*  "Archives  de  Physiologie,"  p.  160,  etc.     Paris,  1868. 


MORBID  ANATOMY  OF  TABES  SPINALIS.  37 

arthropathy  of  the  left  knee.  The  femoro-tibial  joint  was 
enlarged,  the  patella  raised  by  a  small  quantity  of  fluid, 
and  the  leg  could  be  rotated  and  moved  laterally  much 
more  extensively  than  in  the  normal  state.  The  circum- 
ference of  the  left  knee  was  four  centimetres  larger  than  that 
of  the  right.  Cutaneous  sensibility  was  hardly  affected,  while 
the  muscular  sense  was  much  diminished,  and  ataxy  was 
marked.  Buzzard,  who  was  the  first  to  draw  the  attention 
of  the  profession  in  this  country  to  the  arthropathy  of  tabes, 
believes,  from  the  frequent  co-existence  of  gastric  crises 
with  that  condition,  that  a  lesion  of  a  structure  adjacent  to 
the  nuclei  of  the  vagus  in  the  medulla  oblongata  may  be 
found  to  explain  the  osseous  affection;  but  as  neuritis  and 
consequent  atrophy  of  articular  nerves  has  now  been 
shown  to  exist  in  such  cases,  this  theory,  which  presup- 
poses the  existence  of  an  unknown  and  problematical 
centre  for  the  nutrition  of  joints  and  bones,  will  have  to 
be  definitively  abandoned. 


38  SCLEROSIS  OF  THE  SPINAL   COED. 


CHAPTER  III. 

PATHOGENESIS  OF  TABES. 

Having  in  the  last  chapter  given  a  concise  description  of 
the  morbid  appearances  in  the  different  portions  of  the 
nervous  system  met  with  in  tabes,  we  have  now  to  con- 
sider the  question  which  of  the  numerous  alterations  that 
we  have  found  to  exist  is  the  primary  and  essential  one, 
and  what  is  the  exact  pathological  nature  of  the  change. 
It  is  quite  impossible  for  me  to  even  allude  to  all  the 
numerous  theories  which  have  from  time  to  time  been 
started  with  reference  to  these  points,  and  I  must  confine 
myself  to  the  discussion  of  the  newest  and  most  important 
amongst  them. 

1.  When  Dachenne  was  under  the  impression  that  he  had 
discovered  a  new  disease,  "  locomotor  ataxy,"  he  thought 
that  the  cerebellum  must  be  the  seat  of  the  malady ;  and 
more  recently  Neftel,  of  New  York,  has  asserted  that 
tabes  is  really  an  affection  of  the  brain,  and  that  all  other 
alterations  which  may  be  found  must  be  secondary  to  the 
cerebral  lesion.  But  what  does  pathology  teach  us?  We 
have  seen  in  the  preceding  chapter  that,  as  a  rule,  the 
morbid  alteration  stops  short  in  the  medulla  oblongata,  and 
that  changes  in  the  cortex  and  other  portions  of  the  brain 
have  only  been  found  in  exceptional  instances,  where 
towards  the  end  tabes  had  become  complicated  with 
epilepsy,  general  paralysis  of  the  insane,  and  other  similar 
conditions.  It  is  quite  true  that  we  meet  occasionally  in 
the  initial  stage  of  tabes  with  temporary  mental  affec- 
tions,  and  with  aphasia,  apoplexy,  hemiplegia,  and  other 


PATHOGENESIS   OF   TABES.  39 

symptoms  pointing  to  cerebral  disturbance;  but  all  these 
symptoms  are  fleeting  and  evanescent.  They  occur  chiefly, 
and  perhaps  exclusively,  in  syphilised  subjects,  who  are, 
some  years  after  the  primary  affection,  liable  to  similar 
symptoms,  even  where  no  signs  of  tabes  have  made  their 
appearance;  and  they  are  part  and  parcel  of  the  congestive 
form  of  brain-syphilis.  They  are  also  liable  to  occur  in 
alcoholism,  senile  dementia,  general  paralysis  of  the  insane, 
and  insular  sclerosis.  There  is  loss  of  consciousness, 
aphasia,  monoplegia  or  hemiplegia,  coming  on  suddenly 
and  lasting  an  hour  or  two,  or  at  most  a  few  days,  or  a 
week,  showing  that  there  is  no  serious  brain-lesion. 

The  theory  of  the  cerebral  origin  of  the  disease  seems, 
therefore,  to  rest  only  on  certain  somewhat  imperfectly 
understood  clinical  observations;  while  the  pathological 
evidence  of  innumerable  well- observed  cases  is  directly 
antagonistic  to  it;  and  I  therefore  do  not  consider  it 
necessary  to  adduce  further  arguments  against  its  accept- 
ance. 

2.  Another  theory,  which  is  only  held  by  a  few,  is  that 
that  universal  scapegoat,  the  sympathetic  system  of  nerves, 
is  at  the  bottom  of  the  complaint.  We  have  seen  that 
disintegration  of  the  fibres  and  ganglionic  cells  of  this 
portion  of  the  nervous  system  does  undoubtedly  occasion- 
ally occur  in  advanced  cases  of  tabes.  But  to  conclude 
from  this  that  the  sympathetic  is  primarily  affected,  and 
and  that  thence  springs  alteration  of  blood-vessels  and 
wasting  of  nerve-tubes,  constitutes  a  salto  mortale  which  is 
somewhat  too  hazardous  for  us  to  follow.  No  doubt  the 
principal  reason  for  rejecting  this  view  is  that  the  altera- 
tions alluded  to  are  exceptional.  Moreover  Vulpian  has 
very  properly  drawn  attention  to  the  circumstance  that, 
even  in  health,  the  more  intimate  structure  of  the 
sympathetic  is  by  no  means  invariably  the  same.  Great 
variations  occur  in  healthy  subjects  in  the  proportion 
of  nerve-fibres   furnished    with    a    medullary  sheath  and 


40  SCLEROSIS  OF  THE  SPINAL  CORD. 

Remak's  fibres,  and  also  in  the  size  and  pigmentation  of 
the  ganglionic  cells.  But  even  supposing  that  there  was  a 
constant  and  well-demonstrated  change  in  the  sympathetic 
nerve,  it  would  even  then  be  impossible  to  explain  why 
this  should  lead  as  a  rule  only  to  affection  of  the  posterior 
columns,  and  not  of  the  other  constituents  of  the  spinal 
cord. 

3.  Tacasz  and  others  have  broached  the  view  that  the 
primary  event  is  atrophy  of  the  posterior  nerve-roots,  and 
that  the  disease  creeps  from  there  upwards  to  the  substance 
of  the  cord  itself,  like  an  ascending  neuritis.  It  is  quite 
true  that  at  an  advanced  stage  of  the  malady  the  posterior 
roots  are  habitually  as  much  affected  as  the  posterior 
columns  ;  but  the  roots  never  suffer  to  the  exclusion  of  the 
columns.  Moreover,  such  careful  observers  as  Jadersholm, 
Westphal,  and  Tuczek,  have,  in  early  cases  of  tabes,  found 
the  roots  healthy  when  there  was  already  unmistakable 
disease  in  the  columns;  and  this  is  a  death-blow  to  the 
posterior-root  theory. 

4.  A  theory  recently  brought  forward  by  Herbert  Page^ 
seeks  the  starting-point  of  this  formidable  malady,  at 
least  sometimes,  in  a  corn  I  Here  we  seem  to  have 
arrived  at  the  infinitely  little,  in  order  to  account 
for  a  great  deal.  The  prevention  of  tabes  would,  ac- 
cording to  this  theory,  rest  with  the  chiropodists.  Page 
says  that  tabes  dorsalis  may  in  some  cases  have  a  peri- 
pheral beginning,  and  that  a  painful  corn  under  the  meta- 
tarso-phalangeal  joint  is  a  by  no  means  trifling  affection, 
little  deserving  of  treatment.  Perforating  ulcer  is,  accord- 
ing to  him,  a  symptom  or  consequence  of  some  nutritive 
derangement  of  the  affected  part,  and  in  such  cases  the 
disease  may  have  really  begun  at  the  peripheral  parts  of 
the  nervous  system,  so  that  the  nerve-lesion  was  originally 
caused  by  the  continued  painful — often  severely  painful — 

^  "Brain,"  October,  1883,  p.  368. 


PATHOGENESIS  OF  TABES.  41 

pressure  of  the  corns,  the  protracted  sensory  disturbance 
giving  rise  to  ultimate  structural  change  ;  and  that  in  the 
course  of  time  the  degeneration,  travelling  upwards,  reached 
the  spinal  cord,  and  then,  and  only  then,  gave  rise  to  the 
symptoms  of  tabes  dorsalis  !  This  author  thinks  that  his 
view  is  supported  by  the  recent  researches  of  Pitres  and 
Vaillard  on  non-traumatic  peripheral  neuritis,  and  adds  an 
instructive  case,  in  which-  a  corn  seemed  the  starting- 
point  of  all  the  troubles  which  the  patient  subsequently 
experienced. 

It  appears  to  us  that  the  discomfort  which  the  majority  of 
Europeans  habitually  experience  from  corns  is  bad  enough, 
without  crediting  these  little  pests  with  such  wickedness 
as  eventually  to  conduce  to  tabes.  That  corns,  especially 
in  certain  positions,  may  be  often  the  beginning  of  nutri- 
tive changes  in  a  limb  seems  probable  enough.  But  in 
the  case  just  mentioned  an  important  link  is  wanting, 
inasmuch  as  it  has  not  been  shown  that  the  patient  was 
free  from  disease  of  the  cord  at  the  time  when  the  corn 
commenced  to  give  trouble.  The  sequence  of  events  is 
much  more  likely  to  be  as  follows  : — Tabes,  from  whatever 
cause,  is  the  primary  change.  This  induces  liability  to 
peripheral  nerve-disturbance,  so  that  certain  exciting  causes, 
such  as  long-continued  pressure  or  injury  to  structures,  are 
more  likely  to  lead  to  mischief  than  in  healthy  persons 
whose  vitality  is  not  defective,  and  in  whom  the  nutrition 
is  not  impaired  by  disease  or  degeneration  of  the  nervous 
centres.  In  this  respect  the  observations  of  Pitres  and 
Vaillard  are  highly  suggestive,  as  showing  that  the  peri- 
pheral nerve-lesion  is  not  by  any  means  continuous  between 
the  distal  extremity  of  the  nerve  and  the  spinal  cord,  but 
that,  on  the  contrary,  the  large  nerve-trunks  between  the 
periphery  and  the  cord  are  healthy.  There  is,  therefore,  no 
creeping  upwards  of  a  peripheral  neuritis  to  the  cord,  but 
we  have  rather  to  do  with  neuritis  excited  by  a  local  cause 
and  confined   to  peripheral    nerve-terminations,   but    pro- 


42  SCLEROSIS  OF  THE  SPINAL  CORD. 

moted  by  insufficient  resistance  in  the  nerve-centre  pre- 
viously diseased.  Moreover,  it  lias  been  shown  that  this 
form  of  peripheral  neuritis  is  not  by  any  means  confined 
to  tabid  subjects,  but  that  it  is  also  liable  to  occur  after 
cerebral  haemorrhage,  fracture  of  the  skull,  herpes  zoster, 
leucocythaemia,  alcoholism,  smallpox,  diphtheria,  and  other 
distempers. 

5.  The  changes  v^hich  I  have  described  as  habitually 
found  in  the  pia  mater  (p.  14)  have  induced  some  observers, 
such  as  Arndt,  Waldmann,  and  others,  to  think  that  lepto- 
meningitis is  the  primary  event,  and  the  actual  cause  of  the 
wasting  of  the  posterior  columns,  and  that  the  change  in  the 
cord  is  a  secondary  degeneration.     This  opinion,  however, 
is  contradicted  by  two   series  of  facts,  viz.,  first  by  cases 
of  undoubted  meningitis,   in  which  the  lesions  peculiar  to 
tabes  have  been   absent  ;  and,  second,  by  cases  of  initial 
tabes,  in  which  no  spinal  meningitis   existed.     As  tabes 
has  in  general  no  tendency  to  shorten  life,  cases  in  the  first 
stage  of  the  disease  rarely  come  on  the  post-mortem  table. 
Quite  recently,  however,  Striimpell  has  carefully  examined 
the  cord  of  a  woman  who  had  only  for  a  short  time  suffered 
from  the  malady,  and  who  had  died  of  typhoid  fever.     She 
had  had  lightning  pains  for  two  years,  and  showed  absence 
of  knee-jerk,  reflectory  pupillary  rigidity,  and  ptosis  of  the 
left  upper  eyelid.     To  the  naked  eye  the  cord   appeared 
healthy  ;  J)ut  on  microscopic  examination  it  was  discovered 
that  the  posterior  columns  were  affected  with  degeneration 
in  their  entire  extent,  from  the  middle  portion  of  the  cer- 
vical region  down  to  the  lower  portion  of  the  lumbar  region. 
Yet   there  was  no  spinal  meningitis.    Again,  Tuczek  has 
lately    examined  four  cases  of    initial  tabes,  which    had 
been     produced    by     ergotism,    and     found    sclerosis     of 
Burdach's    columns  from    the  lumbar   portion  up   to   the 
medulla   oblongata  ;    yet  in  all    of  them  the  pia  spinalis 
was    perfectly    healthy.     It    has    also    been   occasionally 
noticed  that  there  was  no  exact  proportion  in  the  degree 


PATHOGENESIS  OF  TABES.        '  43 

of  morbid    changes  found    in    the  membrane,  on  the   one 
hand,  and  in  the  cord  on  the  other  hand. 

As  the  distribution  of  blood-vessels  is  the  same  through- 
out the  different  portions  of  the  pia  spinalis,  showing  no 
peculiarities  whatever  in  the  part  corresponding  to  the 
posterior  columns,  which  would  distinguish  it  from  that 
investing  the  antero-lateral  columns,  it  has  been  considered 
singular  that  the  inflammatory  appearances  should  be  quite 
confined  to  the  posterior  portion  of  the  membrane.  It  has 
been  argued  that  this  is  owing  to  the  exquisite  sensibility 
which  exists  in  the  corresponding  portion  of  the  cord,  where 
any  irritative  influence  is  more  likely  to  be  felt  and  resented 
than  in  the  antero-lateral  columns.  These  latter  have,  it 
is  true,  a  slight  degree  of  sensibility,  but  it  is  recurrent, 
not  very  keen,  and  certainly  not  to  be  compared  with  that 
of  the  posterior  columns.  When  an  irritant  influence, 
therefore,  acts  on  the  superficial  portion  of  the  posterior 
columns,  it  would  prima  fade  be  probable  that  it  would 
also  act  on  the  corresponding  portion  of  the  pia.  It  is  in 
the  posterior  portion  of  the  spinal  pia  that  we  see  the 
characteristic  granulations  of  subacute  tubercular  menin- 
gitis ;  and  the  localisation  of  these  can  certainly  not  be 
considered  accidental.  These  considerations,  however 
plausible,  seem  yet  controverted  by  the  circumstance  that 
posterior  lepto-meningitis  is  not  constant,  and  occurs  only 
in  the  later  stages  of  tabes,  when  not  only  finer  changes  have 
taken  place  in  the  intimate  structure  of  the  nerve-tubes, 
but  when  gross  alterations  are  perceptible  to  the  naked  eye, 
and  the  size  and  consistency  of  the  posterior  columns  have 
been  markedly  affected.  Perhaps  it  will  appear  to  be, 
therefore,  more  in  accordance  with  all  the  facts  known  at 
present  to  assume  that  the  process  is  rather  mechanical  in 
character,  and  that  the  thickening  of  the  pia  helps  to  fill 
up  the  vacuum  which  is  produced  by  the  shrinking  and 
wasting  of  the  posterior  columns.  The  view  that  the 
peculiar  lightning  pains  of  tabes  are  caused  by  inflamma- 


44  SCLEROSIS  OF  THE  SPINAL  CORD. 

tion  of  the  pia  can  certainly  not  be  maintained,  as  these 
have  been  observed  long  antecedent  to  any  alteration  of 
that  membrane. 

6.  All  om'  present  real  knowledge  of  the  pathology  of  tabes 
converges,  therefore,  to  the  conclusion  that  the  disease  is 
primarily  one  of  the  spinal  cord,  and  more  especially  of  its 
posterior  columns.  Differences  of  opinion,  however,  still 
exist  concerning  the  tissue  in  which  the  malady  actually 
begins.  Is  the  fault  primarily  located  in  the  blood-vessels, 
the  neuroglia,  or  the  nerve-tubes  themselves  ? 

a.  The  blood-vessels  of  the  cord  have,  by  Ordonez,  been 
said  to  be  the  starting-point  of  the  degeneration.  This 
able  histologist  has  described  an  initial  lesion  of  the 
arterioles  of  the  posterior  columns,  the  coats  of  which  he 
found  choked  up  with  oil- globules  and  granular  corpuscles. 
Such  a  condition,  according  to  him,  must  needs  conduce 
to  imperfect  exchange  of  nutritive  material  between  the 
vessels  and  the  tissues,  and  therefore  to  atrophy  and 
sclerosis  of  the  nervous  structures.  This  view  of  Ordonez, 
which  has  been  broached  with  considerable  acumen,  has, 
however,  been  controverted  by  Vulpian,^  who  objects  to  it 
that,  while  the  lesions  of  the  nerve-tubes  in  tabes  are  con- 
stant, the  vascular  changes  are  variable  and  often  absent. 
Moreover,  it  should  be  remembered  that  alterations  in  the 
blood-vessels  similar  to  those  occasionally  observed  in  tabes 
occur  in  Wallerian  degeneration,  that  is,  after  experimental 
section  of  nerves  in  animals  ;  and  that  they  are  for  this 
reason  more  probably  the  consequence  than  the  cause  of 
the  changes  which  take  place  in  the  nervous  structures. 

The  views  of  Ordonez  have,  however,  quite  recently 
found  a  striking  confirmation  by  Be  van  Lewis,^  who 
found  in  a  cord  sent  to  him  by  Buzzard  for  examina- 
tion, most  unquestionable  appearances  of  peri-arteritis 
in    the    blood-vessels    of    the    posterior    columns,    which 

^  "Maladies  du  Systeme  Nerveux,"  p.  385.     Paris,  1879. 
2  <« Brain,"  p.  467.     January,  1884. 


PATHOGENESIS  OF  TABES.  45 

had  apparently  originated  in  the  membranes,  more  espe- 
cially the  posterior  portion  of  the  pi  a,  and  had  from 
there  spread  inward  along  the  vessels  of  the  posterior 
columns.  The  vessels  of  the  latter  were  extremely 
numerous  and  dilated  ;  their  coats  thickened  and  diseased. 
The  wide-stretched  orifices  of  these  numerous  vessels 
formed  invariably  the  centre  of  a  patch  of  fasciculated 
sclerosis.  In  vertical  sections  of  the  sclerosed  parts  dis- 
eased vessels  were  seen  in  large  numbers  with  ampullar 
enlargements  along  their  course,  which  were  owing  to 
vast  accumulations  of  large  nucleated  cells  occupying 
the  peri- vascular  sheath  of  the  vessel.  The  actual  calibre 
of  the  vessel  was  sometimes  dilated  ;  at  other  times  it  was 
constricted  by  the  encircling  mass  of  cells  ;  whilst  occa- 
sionally, although  rarely,  a  genuine  aneurismal  condition 
of  the  vessel  had  been  produced  along  its  diseased  tunics. 
It  therefore  appeared  that  the  whole  dorsal  region  of  the 
cord  had  been  subjected  to  an  invasion  by  an  extensive 
peri-arterial  affection,  and  its  medullated  strands  exposed 
to  destructive  pressure  from  nodular  outgrowth  on  the 
vessels.  The  peri-arteritis,  originating  in  the  membranes 
and  spreading  inwards  to  the  posterior  columns,  would 
therefore,  in  that  case,  have  played  the  chief  part  in  the 
production  of  the  lesion  to  which  both  Burdach's  and 
Goll's  columns  had  succumbed. 

Bevan  Lewis's  account  of  the  post-mortem  appearances 
in  this  case  is  a  model  of  what  such  descriptions  should 
be,  and  can  leave  no  doubt  whatever  on  the  mind  that 
cases  occur  in  which  the  vascular  change  is  the  primary 
one  ;  yet  probably  such  cases  are  rare,  as  many  good  ob- 
servers appear  never  to  have  met  with  them. 

b.  Another  theory  which  has  been  brought  forward  more 
particularly  by  Adamkiewicz  is  that  the  essential  lesion  of 
tabes  consists  of  interstitial  degeneration  of  intertubular  con- 
nective tissue,  and  not  of  primary  degeneration  of  nerve- 
fibres.     According   to  this    author,   the    connective  tissue 


46  SCLEROSIS  OF  THE  SPINAL  CORD. 

becomes  sclerosed  in  tracts  corresponding  to  the  course  of 
the  blood-vessels,  and  the  sclerosis,  once  commenced,  has  the 
tendency  to  creep  on  in  the  interstices  of  the  parenchyma  of 
the  cord.  Wherever  connective  tissue  enters  from  without 
into  the  posterior  columns,  that  is,  at  the  posterior  fissure 
of  the  cord  and  at  the  boundary  between  Burdach's  and 
Goll's  columns,  there  the  sclerosis  is  active,  and  strangles 
the  nerve-fibres.  This  he  believes  to  be  in  consonance 
with  the  theory  of  the  syphilitic  origin  of  tabes,  as  syphilis 
is  known  to  give  rise  to  interstitial  degeneration ;  and  the 
process  is  said  to  be  analogous  to  cirrhosis  of  the  liver, 
which  consists  likewise  of  interstitial  degeneration  of  con- 
nective tissue. 

This  view,  which  has  been  very  confidently  put  forward, 
is  based  on  the  observation  of  a  very  small  number  of  cases, 
none  of  which  appear  sufiiciently  well  marked  to  carry  con- 
viction to  our  mind,  even  as  far  as  they  go.  On  the  other 
hand,  a  much  larger  class  of  cases  is  on  record  which  speak 
directly  against  the  hypothesis  just  mentioned  ;  and  what 
is  even  more  important  is  the  circumstance  that,  if  we  were 
to  accept  this  theory  we  should  find  it  impossible  to  under- 
stand why  a  disease  which  primarily  affected  the  neuroglia 
should  be  so  strictly  localised  to  certain  systems  of  the  cord 
as  tabes  has  been  shown  to  be.  The  anatomical  distribution 
of  the  connective  tissue  is,  like  that  of  the  blood-vessels, 
exactly  the  same  in  all  the  different  systems  and  strands  of 
the  cord  ;  whereas  we  have  seen  that  the  nerve-tubes  form 
separate  and  perfectly  distinct  groups  and  systems,  which 
belong  evolutionally  together,  and  become  successively  de- 
veloped at  special  periods  of  embryonic  life,  constituting 
functionally  separate  groups,  of  which  it  is  easy  to  under- 
stand why  they  should  respond  differently  to  various  inju- 
rious influences  which  may  be  brought  to  bear  upon  them 
during  some  period  of  the  struggle  for  existence. 

Another  reason  which  speaks  against  the  connective- 
tissue  theory  is,  that  we  find,  in  cases  where  there  is  un- 


PATHOGENESIS  OF  TABES.  47 

questionably  interstitial  inflammation  of  peripheral  nerves, 
as  in  some  forms  of  neuritis  descendens,  plenty  of  healthy 
nerve-tubes  left,  while  the  neurilemma  and  the  interstitial 
connective  tissue  are  considerably  proliferated.  If  therefore 
the  neuroglia  were  primarily  affected  in  tabes,  we  should  no 
doubt  discover  numbers  of  healthy  nerve-tubes  in  the  pos- 
terior roots  and  columns,  together  with  overgrowth  of  the 
glia.  Such,  however,  is  not  the  case,  and  this  also  leads 
to  the  conclusion  that  in  tabes  parenchymatous  disease 
precedes  interstitial  disease. 

c.  While,  therefore,  general  considerations,  based  on  well- 
ascertained  evolutional  and  functional  differences  between 
the  several  tracts  of  fibres  in  the  cord,  point  clearly  to  the 
conclusion  that  the  central  nerve-tnbe  is  primarily  affected 
in  tabes  ;  and  while  direct  observation  of  glia-changes 
has  failed  to  prove  that  they  arise  independently  of  tube- 
changes,  we  have,  nevertheless,  in  the  last  resort  to  appeal 
to  direct  observation  of  the  alterations  found  in  the  nerve- 
fibres  for  the  decision  of  this  question. 

Now  it  is  found  that  the  first  pathological  change  which 
takes  place  generally  affects  the  axis-cylinder  of  the  central 
nerve-fibre.  From  a  functional  point  of  view,  this  is  the 
principal  constituent  of  the  nerve-tube  ;  and  most  pro- 
bably irritation  of  it  gives  rise  to  those  attacks  of  light- 
ning pains,  which  form  in  general  the  most  prominent 
symptom  of  the  first  stage  of  the  disease.  Repeated 
attacks  of  irritation  lead  to  imperfect  nutrition,  and  finally 
to  atrophy.  The  dead  axis-cylinder  then  acts  as  a  foreign 
body,  and  causes  further  irritation  in  the  neighbourhood. 
The  nuclei  of  the  nerve-fibres  swell  and  multiply  ;  the 
protoplasma  surrounding  the  nuclei  begins  to  proliferate, 
the  myeline  sheath  becomes  segmented,  and  ultimately 
reduced  to  small  drops  and  granulations,  which  even- 
tually disappear  in  their  turn.  The  irritation  is  now 
likewise  propagated  to  the  intertubular  connective  tissue, 
the   cells    of   which  begin   to    multiply,  while    the   fibres 


48  SCLEROSIS  OF  THE  SPINAL  CORD. 

proliferate.  The  coats  of  the  blood-vessels  then  partici- 
pate in  the  disease,  and  the  white  blood-globules  are 
changed  into  a  granular  mass.  Such  a  morbid  process 
therefore  appears  to  be  rather  one  intermediate  between 
atrophy  and  inflammation  ;  and  this,  apart  from  every- 
thing else,  fits  in  much  better  with  other  facts,  inasmuch  as 
we  can  readily  understand  why  atrophy  should  be  limited 
to  certain  sets  of  fibres  ;  while,  if  inflammation  invaded  the 
structures,  one  does  not  see  why  it  should  not  spread  con- 
tiguously to  other  tracts  of  nerve-tubes,  like  ordinary  mye- 
litis, seeing  that  the  distribution  of  the  connective  tissue 
and  of  the  blood-vessels  is  everywhere  uninterruptedly 
the  same. 

On  reviewing  t-he  whole  of  the  morbid  changes  which 
are  found  to  take  place  in  tabes,  they  appear  to  us  of 
an  extremely  complex  character.  They  certainly  do  not 
constitute  simply  "sclerosis  of  the  posterior  columns," 
although  this  is  undoubtedly  the  most  important  and 
fundamental  lesion.  Nor  can  we  quite  agree  with  the 
ingenious  and  brilliant  theory  of  the  disease  which  has 
been  put  forward  by  Pierrot. ^  According  to  this  observer, 
tabes  consists  anatomically  of  inflammatory  alterations 
which  have  their  principal  seat  at  two  points,  viz.,  1st, 
in  the  peripheral  receptive  organs,  such  as  the  retina,  the 
auditory  nerve,  etc.,  and  2nd,  in  the  columns  and  sensory 
ganglia  of  primary  and  secondary  reflex  action. 

The  principal  symptoms  therefore  consist  of  various 
disturbances  of  general  and  special  sensibility,  while  the 
disturbances  of  motor  function,  which  likewise  occur, 
are  to  be  explained  by  the  intimate  relations  existing 
between  the  motor  and  sensory  tracts  ;  and  those  dis- 
turbances which  occur  in  the  vascular  sphere,  must  be  re- 
ferred to  implication  of  the  vaso-motor  system,  which  is' 

^  "Essai  sur  les  Symptomes  cephaliques  du  Tabes  Dorsalis,"  Paris, 
1876 ;  and  "  Transactions  of  the  International  Medical  Congress  of 
London,"  1881,  vol.  i.,p.  399. 


PATHOGENESIS  OF  TABES.  49 

intermediate  between  the  motor  and  sensory  tracts,  passing 
from  the  cord  to  the  medulla  oblongata,  through  the  medium 
of  the  posterior  pyramids.  The  disease  is  therefore  by  Pierret 
and  his  pupils  often  called  "  sensitive  tabes." 

Now  there  can  be  no  doubt  that  "all  movements  are 
performed  under  the  influence  of  sensory  impressions,  and 
that  the  motor  nerve  nuclei  are  educated  for  co-ordinated 
action  by  corresponding  sensory  nuclei."  (Broadbent.) 
This  theory  will  explain  the  phenomena  of  ataxy,  but  is 
insufficient  to  account  for  the  occurrence  of  actual  para- 
lysis. It  is,  however,  a  fact  that,  to  mention  only  the 
cranial  nerves,  the  third  and  sixth,  which  are  purely  motor 
in  their  function,  are  frequently  affected  in  tabes,  while 
paralysis  of  the  portio  dura  and  the  motor  portion  of  the 
fifth  nerve  has  likewise  been  observed.  In  order,  appa- 
rently, to  get  over  this  difficulty  Pierret  states  that  in 
certain  fishes,  such  as  Lepidosiren,  the  muscles  of  the  eye 
receive  their  branches  from  the  fifth  nerve,  and  that  in  the 
Amphibia  the  sixth  nerve,  which  supplies  the  rectus  ex- 
ternus  muscle,  is  not  separated  from  the  fifth.  These  con- 
siderations, which  are  derived  from  compared  anatomy,  are, 
however,  not  applicable  to  buman  physiology  or  pathology ; 
nor  is  it  possible  to  agree  with  Pierret  in  thinking  that  all 
palsies  which  occur  in  the  course  of  tabes  have  to  be 
looked  upon  as  reflex  neuroses. 

Paralysis  of  the  rectus  externus  occurs  sometimes  years 
before  the  appearance  of  lightning  pains  or  other  sen- 
sory disturbances,  and  cannot  by  any  stretch  of  imagi- 
nation be  looked  upon  as  reflex  paralysis.  Then,  again, 
paralysis  of  certain  sets  of  muscles  of  the  body  and 
limbs  is  not  at  all  uncommon  in  tabes  ;  and  so  is  mus- 
cular atrophy,  owing  to  wasting  of  the  ganglionic  cells 
in  the  anterior  cornua  of  the  grey  matter.  All  these  signs 
appear  to  us  totally  incompatible  with  the  sensory  theory  of 
tabes,  which,  although  applicable  to  a  considerable  number 
of  the  symptoms  which  are  observed  in  that  extraordinary 


50  SCLEROSIS  OF  THE  SPINAL  CORD. 

disease,  cannot  cover  the  whole  of  them,  unless  some 
obstinate  and  unruly  ones  are  placed  in  the  bed  of  Pro- 
crustes, to  be  either  cut  off  altogether  or  to  be  pulled  out 
of  all  their  original  shapes,  so  as  no  longer  to  resemble 
their  natural  selves.  The  time  has  evidently  not  come 
yet  for  "  crowning  the  edifice,"  that  is,  for  building  up  a 
theory  of  tabes  which  will  account  for  all  phenomena  of  the 
malady  ;  and  a  great  deal  of  painstaking  observation  will 
be  required  before  this  desirable  object  has  any  chance  of 
being  accomplished.  What  we  can  say  with  certainty  is  that 
the  anatomical  as  well  as  clinical  features  of  tabes  are  of  an 
extremely  complex  character  ;  that  they  vary  greatly  in  different 
cases ;  that  the  mode  in  which  they  are  grouped  together  has,  as 
yet,  not  been  found  to  follow  a  definite  law ;  and  that  it  would 
be  premature  to  commit  us  to  any  positive  or  dogmatic  view  of 
the  nature  of  the  disease. 


51 


CHAPTER  ly. 

MORBID  ANATOMY  OF  OTHER  EORMS  OF  SCLEROSIS. 

1.  Primary   sclerosis  of  the  lateral  columns. — The   next 
form  of    sclerosis    which   we    have    to    consider   is    that 
which  is  believed  to  form  the  material  base  of  simstic  S2nnal 
'paralysis,   or    spasmodic   tabes   dorsalis,    and    to   consist   of 
primary  symmetrical  sclerosis  of  the  lateral  columns.     This 
disease,  the  symptoms  of  which  are  well  known,  seems  as 
jet  to  have  eluded  the  grasp  of  the  pathologist.    Ross,^  of 
Manchester,  attributes  to  his  colleagues,  Professors  Morgan 
and  Dreschfeld,  of  that  city,  the  honour  of  having  been 
the  first   to    prove   by   dissection   the   connexion   of    the 
symptoms  of  spastic  paralysis  with  lateral  sclerosis  in  a 
primary  and  uncomplicated  case  of  the  disease,  and  says 
that   they    found   symmetrical    sclerosis    of    the    crossed 
pyramidal  strands  from  the  medulla  oblongata  to  the  conus 
medullaris,  and  an  entire  absence  of  any  other  lesion.     The 
same  opinion  is  expressed  by  Charlton  Bastian^  and    by 
Russell,^  of  Birmingham.    The  account,  however,  given  by 
Dreschfeld,  both  in  the  "  Transactions  of  the  International 
Medical  Congress,"  and   in   the  "  Journal  of   Anatomy  " 
(1881),    shows    quite  clearly  that  his   case  was  not   one 
of  uncomplicated  lateral  sclerosis,  inasmuch  as  the  giant-cells 
of  the  grey  anterior  cornua  were  likewise  affected.     He  says 

•"A  Treatise  on   Diseases  of  the  Nervous  System,"   2nd  edition, 
vol.  ii.,  p.  82.     London,  1883. 

2*' A  Dictionary  of  Medicine,"  by  Richard  Quain,  M.D.,  F.R.S., 
p.  1486.     London,  1883. 

•^  "Medical  Times  and  Gazette,"  Feb.  11,  1884. 

E  2 


52  SCLEROSIS  OF  THE  SPINAL  CORD. 

that  in  his  case  the  brain  and  medulla  oblongata  were 
apparently  healthy;  that  the  spinal  cord  showed  to  the 
naked  eye  nothing  but  slight  softening  in  the  dorsal 
region;  but  that  the  microscopic  examination  of  the  speci- 
men showed  the  neuroglia  in  the  anterior  pyramids  of  the 
bulb  to  be  slightly  increased,  the  anterior  and  lateral 
pyramidal  strands  extensively  diseased,  chiefly  in  the 
cervical  and  lumbar  region  of  the  cord;  while  the  multi- 
polar ganglionic  cells  of  the  anterior  grey  cornua  were 
found  wasted  from  the  upper  dorsal  region  down  into  the 
lumbar  portion  of  the  cord.  There  wag  simple  atrophy, 
pigmentary  atrophy,  and  occasionally  complete  absence  of 
whole  groups  of  these  cells.  The  case  is  therefore  seen  to 
be  one  of  the  amyotrophic  variety  of  the  disease,  and  not 
one  of  uncomplicated  lateral  sclerosis. 

Most  other  cases  which  have  until  now  been  recorded  are 
equally  unsatisfactory,  for  one  reason  or  another.  Charcot 
and  Pitres  have  described  one  which  was  during  life 
diagnosed  as  one  of  primary  lateral  sclerosis,  but  turned 
out  on  the  post-mortem  table  to  be  one  of  insular  dissemi- 
nated sclerosis.  Schultze  has  described  four  cases  in  which 
the  symptoms  of  lateral  sclerosis  were  present;  and 
eventually  discovered  in  two  of  them  a  tumour  of  the 
brain,  while  the  third  was  one  of  chronic  internal  hydro- 
cephalus, the  latter  even  without  a  trace  of  sclerosis. 
In  another  case  there  was  found  myelitis  from  compression, 
or  rather  dorsal  hypertrophic  pachymeningitis,  the  dura 
mater  being  very  much  thickened,  more  particularly 
laterally,  and  showing  purulent  detritus  on  its  inner 
surface,  the  pia  having  become  attached  to  it,  and  the 
cord  being  flattened,  compressed,  and  softened.  Aufrecht 
and  Hopkins  have  more  recently  recorded  cases  in  which 
there  were  the  symptoms  of  spastic  paralysis  during  life, 
and  lateral  sclerosis  was  discovered  after  death,  again, 
however,  complicated  with  atrophy  of  the  anterior  cornual 
cells.     In    Hopkins's    case   the   lateral    columns    and   the 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.      53 

adjoining  portion  of  the  anterior  columns  proved  to  be 
nearly  devoid  of  nerve-tubes  at  the  lower  end  of  the  cord; 
while  in  the  anterior  columns  overgrowth  of  intertubular 
connective  tissue  was  noticed.  Higher  up  in  the  cord 
more  tubes  were  seen,  and  in  the  mid-dorsal  region  the 
anterior  columns  were  nearly  normal.  Hopkins  does  not 
state  whether  the  sclerosis  was  confined  to  the  pyramidal 
tracts,  or  whether  it  also  affected  the  direct  cerebellar 
column;  but  the  large  cells  of  the  anterior  cornna  were 
much  atrophied  in  the  lower  half  of  the  organ,  except  in  a 
portion  taken  from  the  lumbar  enlargement;  while  a  little 
lower  down,  where  the  cells  were  arranged  in  three  well- 
defined  groups,  viz.,  a  central,  a  larger  antero-lateral,  and 
a  large  postero-lateral,  the  two  first  groups  were  markedly 
atrophic,  more  especially  on  the  right  side. 

The  only  case  which  appears  to  me  to  be  one  of  un- 
doubted and  uncomplicated  primary  lateral  sclerosis  is  one 
which  has  quite  recently  been  recorded  by  Minkowsky.^ 

This  occurred  in  the  University  Hospital  of  Konigsberg, 
under  the  care  of  Professor  Naunyn.  It  was  that  of  a 
girl,  aged  19,  who  was  admitted  for  secondary  syphilis 
in  May,  1881.  The  date  of  the  primary  infection  could 
not  be  ascertained.  She  was  treated  by  inunction,  and 
got  apparently  well;  but  fresh  specific  eruptions  having 
shortly  afterwards  supervened,  she  had  to  be  re-admitted. 
Symptoms  of  phthisis  presently  came  on,  and  likewise 
great  weakness  in  the  lower  extremities,  accompanied 
with  tremor.  In  January,  1882,  she  could  not  walk  without 
support;  when  supported,  the  gait  was  shufiiiug;  she 
could  hardly  lift  the  toes  from  the  ground,  and  there  was 
much  sclerotic  tremor.  The  upper  extremities  appeared 
feeble,  but  not  paralysed.  Sensibility  was  everywhere 
normal.  The  cutaneous  reflexes  were  absent,  but  the 
kneejerk  was   exaggerated  on  both  sides,  and  there  was 

'  "  Deutaches  Archiv  fiir  klin.  Medicin,"  vol.  xxxiv.,  p.  433.    1884# 


54  SCLEROSIS  OF  THE  SPINAL  CORD. 

ancle-clonus.  There  were  no  symptoms  on  the  part  of  the 
bladder  and  rectum.  Inunction  was  now  again  resorted  to, 
and  in  a  little  more  than  a  week  the  tendon  reflexes  ap- 
peared to  be  much  less  marked.  Shortly  afterwards  the 
walk  became  more  certain,  and  the  tremor  ceased.  A 
month  after  admission  the  patient  walked  tolerably  well 
without  support.  The  phthisical  symptoms,  however,  in- 
creased, and  the  general  condition  of  the  patient  now 
became  so  bad  that  the  treatment  by  inunction  had  to  be 
discontinued.  Hectic  fever  supervened,  and  the  girl  died 
in  July,  1882.  The  inspection  showed  to  the  naked  eye  a 
slight  reduction  of  the  postero-lateral  compared  with  the 
antero-lateral  columns;  otherwise  no  change  was  percep- 
tible to  the  unassisted  eye.  After  having  been  hardened  in 
Miiller's  fluid,  the  postero-lateral  columns  showed  a  much 
lighter  colour,  more  especially  in  the  dorsal  portion  of  the 
cord,  and  corresponding  to  the  crossed  pyramidal  and 
direct  cerebellar  column.  Sections  of  the  dorsal  cord 
showed  under  the  microscope  that  the  disease  was  limited 
to  the  strands  just  mentioned.  In  the  crossed  pyramidal 
columns  the  number  of  nerve-tubes  was  much  diminished, 
but  there  were  numerous  fibres  in  a  perfectly  normal  state. 
Some  were  thin,  with  myeline-sheath  atrophied,  and  there 
were  numerous  lacunae  which  evidently  corresponded  to 
wasted  nerve-tubes,  and  where  thin  remains  of  axis- 
cylinders  might  still  be  recognised.  The  neuroglia  was 
somewhat  overgrown,  and  contained  numerous  nuclei,  with 
dilated  blood-vessels  whose  adventitia  was  thickened. 
There  were  a  few  oil-globules  and  amyloid  bodies.  In  the 
direct  cerebellar  column  the  nerve-tubes  appeared  almost 
entirely  perished;  the  intertubular  substance  was  con- 
siderably proliferated,  and  there  were  no  lacunae.  All  the 
other  strands  of  the  white  matter  were  perfectly  normal. 
In  the  whole  of  the  dorsal  portion  of  the  cord  the  anterior 
cornua  of  the  grey  matter  were  jyerfectly  normal ;  the  number 
of    ganglionic    cells   was    large.     In    Clarke's    vesicular 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     55 

columns  the  cells  appeared  slightly  diminished,  and  some 
of  them  contained  a  good  deal  of  brownish  pigment. 
There  were,  however,  no  certain  signs  of  actual  degenera- 
tion there. 

In  the  lumbar  cord  the  wasting  of  nerve-tubes  in  the 
affected  strands  was  much  less  marked,  and  the  grey- 
matter  perfectly  healthy.  In  the  cervical  cord  there  ap- 
peared to  be  a  good  deal  of  difference  between  the  crossed 
pyramidal  and  the  direct  cerebellar  strands,  inasmuch  as 
the  former  showed  very  slight,  and  the  latter  a  very 
marked,  degeneration.  Goll's  columns  appeared  at  first 
sight  to  participate  somewhat  in  the  disease,  but  on  closer 
examination  this  was  shown  not  to  be  the  case.  The  grey 
matter  was  perfectly  normal  in  the  upper  portion,  while  in 
the  lower  there  was  a  slight  effusion  of  blood  at  the 
boundary  between  the  anterior  and  posterior  horns. 

This  case  is  also  interesting  as  showing  that  spastic 
paralysis  may  occur  in  consequence  of  syphilis.  The 
patient  was  a  girl  without  inherited  neurotic  tendency; 
the  disease  appeared  after  infection,  and  was  nearly  cured 
by  specific  treatment.  It  also  shows  that  even  when 
symptoms  of  spinal  disease  disappear,  the  lesion  which 
originally  caused  them  may  still  be  present.  Schultze  has 
seen  a  case  of  tabes  where  the  same  occurred. 


Fig.  7. 
Primary  lateral  sclerosis. 
According  to    Charcot    and    Bouchard,   the    pyramidal 
column  is,  in  primary  lateral  sclerosis  (Fig.  7),  found  studded 


66 


SCLEROSIS  OF  THE  SPINAL  COED. 


with  wedge- shaped  grey  patches,  reaching  anteriorly  as  far 
as  the  lateral  column  proper,  exteriorly  as  far  as  the  pia 
mater,  and  interiorly  as  far  as  the  posterior  cornna.  This 
pecuharity  in  the  localisation  of  the  disease  is  said  to 
distinguish  it  anatomically  from  Tiirck's  degeneration,  or 
secondary  lateral   f^clerosis  consequent  on  cerebral  haemor- 


Ficx.  8. 

Secondary  lateral  sclerosis  after  cerebral  disease. 
(Tiirck's  degeneration.) 

rhage  or  softening,  in  which  the  patches  are  rounded,  not 
wedge-shaped,  and  do  not  spread  exteriorly  as  far  as  the 
pia  mater ;    and  likewise  from   secondary    sclerosis    after 


FiCx.  9. 
Secondary  lateral  sclerosis  after  myelitis. 

myelitis,  hsemorrhage  into  the  cord,  etc.,  (Fig.  9,)  where 
the  grey  patches  do  not  extend  posteriorly  as  far  as  the 
posterior  cornua,  but  where  a  small  intermediate  layer 
of  healthy  white  substance  remains  between  them  and 
the    sclerosed   tissue.     It  has    not    yet   been    ascertained 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.      57 

whether  these  minute  differences  are  at  all  constant  in  the 
different  forma  of  lateral  sclerosis,  and  the  whole  subject 
is  still  involved  in  much  obscurity. 

Ley  den  has  long  ago  expressed  his  disbelief  in  Erb's 
spastic  paralysis  as  a  distinct  disease;  and  has,  in  cases 
which  showed  the  symptoms  described  by  Erb  during  life, 
generally  found  myelitis  of  the  dorsal  portion  of  the  cord. 
According  to  him  these  symptoms  may  be  owing  to 
myelitis  from  injury,  in  the  later  stages  of  which 
muscular  spasms  and  rigidity  are  apt  to  make  their  ap- 
pearance; to  myelitis  from  compression  of  the  cord  by 
carious  vertebrae  or  tumours;  to  syphilis;  to  meningitis,  or 
pio-myelitis  of  acute  or  sub-acute  course;  and  finally  to 
that  form  of  paralysis  which  follows  certain  acute  diseases, 
such  as  typhoid  fever,  smallpox,  relapsing  and  inter- 
mittent fever,  and  the  puerperal  state. 

Apart,  however,  from  these  affections  of  the  spinal  cord 
and  its  membranes,  the  phenomena  of  spastic  paralysis 
may  be  owing,  particularly  in  children,  to  disease  of,  or 
deficiency  in,  the  motor  area  of  the  cortex,  or  of  the  white 
conducting  strands  connecting  the  latter  and  the  anterior 
cornua  of  the  cord.  This  may  be  congenital,  and  a  conse- 
quence of  what  Heschl  has  called  porencephaly.  If  there 
is  a  porencephalous  defect  in  the  central  convolutions  of 
the  brain,  viz.,  the  ascending  frontal  and  the  ascending 
parietal,  then  the  downward  passage  of  the  pyramidal 
strands,  which  proceed  from  the  ganglionic  cells  of  the 
cortex  through  the  crus,  pons,  and  medulla),  oblongata  to  the 
spinal  cord,  must  be  arrested.  If  such  arrest  takes  place 
high  up,  all  four  extremities  would  be  affected  ;  while  if 
lower  down,  only  the  legs  would  suffer  from  spastic  para- 
lysis. In  almost  all  such  cases  there  would,  however,  be  at 
the  same  time  epileptiform  fits,  more  or  less  imbecility,  and 
cerebral  symptoms.  Meschede  has  described  a  case  where 
there  was  a  defect  in  the  parietal  bone,  through  which  the 
brain  could  be  seen  to  pulsate.  After  death  there  was  found 


58  SCLEROSIS  OF  THE  SPINAL  CORD. 

immediately  beneath  tlie  defect  in  the  bone,  in  the  right 
hemisphere,  a  cavity  three  inches  long  and  proportionately 
wide  and  deep,  filled  with  serous  fluid.  This  communicated 
with  the  lateral  ventricles  ;  and  both  ventricles  were  so 
much  distended  by  fluid  that  the  cortex  as  well  as  the 
basal  ganglia  were  compressed.  The  pyramidal  strands 
were  undeveloped.  Kundrat  has  recorded  an  analogous 
case,  in  which  the  left  hemisphere  near  the  island  of  Reil 
was  the  seat  of  a  similar  cavity  ;  the  lateral  ventricles 
were  distended  by  fluid,  and  the  pyramidal  tracts  of  the 
cord  completely  undeveloped.  Similar  cases  have  more 
recently  been  described  by  Ross  and  Hadden.  Where  de- 
livery is  tedious,  more  especially  in  the  case  of  a  first  child, 
the  brain  may  suffer  injury,  either  by  haemorrhage,  soften- 
ing, or  local  encephalitis,  leading  to  atrophy  of  the  motor 
area  of  the  cortex  and  sclerosis  of  the  pyramidal  strands. 
The  symptoms  of  lateral  sclerosis  may  also  be  complicated 
with  general  paralysis  of  the  insane. 

Secondary  sclerosis  of  the  pyramidal  strands  is,  however, 
most  frequently  seen  after  attacks  of  cerebral  haemorrhage, 
involving  the  motor  convolutions  of  the  cortex  of  the  brain, 
or  the  corpus  striatum,  and  after  embolism  and  thrombosis 
of  the  blood-vessels  supplying  these  parts,  more  especially 
the  left  middle  cerebral  artery,  leading  to  softening  of  the 
motor  zone  of  the  brain.  The  degree  and  extent  of  this 
sclerosis  varies.  In  some  cases  the  whole  texture  of  the 
pyramidal  strand  has  been  found  utterly  destroyed,  there 
being  no  nerve-tubes  left,  but  only  amyloid  corpuscles 
and  overgrown  connective  tissue  ;  while  in  other  cases  the 
degenerative  process  appears  to  be  more  limited,  there  being 
white  patches  interspersed  in  the  grey  mass,  containing 
healthy  nerve-tubes.  The  extent  of  the  primary  lesion  in 
the  brain  determines  the  degree  of  the  secondary  sclerosis 
in  the  pyramidal  strand. 

The  sclerosed  appearance  of  this  tract  of  fibres  begins 
immediately  behind  the  lesion,  and  follows  its   anatomical 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     59 

distribution  further  down.  It  is  particularly  marked  in  the 
crus  cerebri,  more  especially  its  middle  portion.  In  the 
pons  Varolii  it  is  not  so  obvious,  but  becomes  again  more 
clearly  apparent  in  the  anterior  pyramid  of  the  medulla 
oblongata,  where  it  crosses  over  to  the  opposite  side  of  the 
cord,  and  runs  down  in  the  posterior  portion  of  the  lateral 
column  until  it  reaches  the  lumbar  enlargement.  This 
sclerosis  leads  to  irritation  in  the  motor  cells  of  the  anterior 
horns  of  the  spinal  cord,  and  thereby  causes  rigidity  of  the 
paralysed  muscles,  which  is  an  exaggeration  of  their  normal 
tonicity.  It  is  only  in  exceptional  cases  that  the  sclerosis 
spreads  from  the  pyramidal  strand  to  the  anterior  horns, 
and  induces  wasting  in  the  giant  cells  of  the  grey  matter. 
Destruction  of  the  centre  of  muscular  tonicity  then  leads  to 
atrophy  of  the  paralysed  muscles,  which  at  the  same  time 
lose  their  rigidity.  All  grey  cells  being  connected,  the 
process  may  spread  from  the  anterior  to  the  posterior 
horns,  or  to  the  anterior  horns  of  the  opposite  side,  by 
means  of  the  anterior  commissure  ;  and  we  have  then  no 
hemiplegia,  but  paraplegia  with  muscular  atrophy.  Some 
of  the  ganglionic  cells  may  be  entirely  gone,  while  those 
which  remain  look  sickly,  yellow,  and  granular,  and  seem 
deprived  of  their  nuclei  and  Deiters's  elongations.  The 
intermedio-lateral  cells,  which  are  believed  to  be  centres 
of  vasomotor  action,  have  likewise  occasionally  been 
found    destroyed 

In  cases  where  decussation  is  incomplete,  sclerosis  is 
found  in  Tiirck's  direct  pyramidal  column  (P,  Fig.  2,  p.  7). 
Flechsig  has  shown  that  total  crossing  of  the  fibres  from 
one  to  the  other  side  only  takes  place  in  a  certain 
number  of  cases;  in  others  there  may  be  total  crossing 
of  one  pyramid  and  semi-decussation  of  the  other,  or 
there  may  be  semi-decussation  of  both  strands.  In  such 
cases  more  than  fifty  per  cent,  of  the  fibres  of  the 
pyramidal  strand  may  remain  uncrossed,  and  then  pro- 
ceed straight  on  to  the  anterior  columns  of  the  same  side. 


60  SCLEROSIS  OF  THE  SPINAL  CORD. 

Sclerosis  may  tlierefore  be  discovered  in  Ijoth  the  crossed 
and  uncrossed  pyramidal  strands.  Bouchard  states  that  the 
■fibres  of  Tiirck's  columns  gradually  vanish  in  the  dorsal 
region  of  the  cord  ;  and  that  in  the  lower  portions  of  the 
organ,  therefore,  only  the  crossed  pyramidal  column  is 
found  sclerosed.  Similarly,  in  compression  of  the  cord, 
descendino;  deg-eneration  is  said  to  be  found  in  Tiirck's 
columns  only,  if  the  seat  of  the  lesion  is  high  up. 
This  statement  has  been  repeated  by  most  subsequent 
writers  on  the  subject,  but  seems  really  to  apply  only  to  a 
limited  number  of  cases. 

Sclerosis  of  that  portion  of  the  lateral  column  which  is  hnown 
as  the  direct  cerebellar  strands  is  generally  connected  with 
other  forms  of  sclerosis,  more  particularly  of  Groll's  and 
the  pyramidal  strands  columns,  and  seems  to  be  always 
secondary  and  ascending.  It  occurs  in  Pott's  disease,  and 
is  generally  associated  with  wasting  of  Clarke's  vesicular 
columns,  which  are  considered  to  be  the  trophic  centre 
of  the  direct  cerebellar  strands. 

2.  Sclerosis  ofGoU's  columns. — Primary  sclerosis  of  Goll's 
or  the  postero-internal  columns  apart  from  any  other  lesion 
is  excessively  rare,  as  up  to  the  present  time  only  three 
such  cases  have  been  placed  on  record,  viz.,  by  Pierret,  Du 
Castel,  and  Gowers.  Combined  and  secondary  sclerosis 
of  these  columns  is,  however,  frequently  discovered. 
It  is  habitually  found  in  cases  of  Pott's  disease  in  the 
dorsal  region  of  the  cord,  and  other  affections  of  the  white 
medullary  matter  lower  down.  It  is  then  called  ascending 
degeneration,  and  is,  as  I  have  just  mentioned,  apt  to 
occur  together  with  sclerosis  of  the  direct  cerebellar  strands. 
It  does  not  follow  disease  of  the  grey  matter  of  the 
cord,  such  as  atrophy  of  the  ganghonic  cells  of  the  anterior 
horns,  in  infantile  paralysis  and  progressive  muscular 
atrophy.  The  crossed  pyramidal  strands  may  be  found  scle- 
rosed together  with  Groll's  columns  and  the  direct  cerebellar 
strands.     All    these  strands  contain  long  fibres,   and  are 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     61 

evolutionally  distinguished  by  a  late  formation  of  their 
myeline  sheaths. 

Ascending  sclerosis  of  GoU's  columns  has  been  experi- 
mentally produced  by  Singer,  who  has  seen  it  to  occur 
after  section  of  the  posterior  roots  of  the  sacral  and  lum- 
bar nerves ;  and  from  this  it  is  concluded  that  these 
columns  consist  almost  exclusively  of  fibres  which  ascend 
from  the  roots  just  mentioned  directly  towards  the  medulla 
oblongata.  An  experiment  made  by  Kahler  leads  to  the 
same  conclusion.  He  injected  liquid  bees-wax  into  the 
epidural  space  from  the  sixth  dorsal  vertebra,  and  this  when 
solidified  compressed  the  cord  as  well  as  the  nerve-roots. 
The  invariable  consequence  was  degeneration  of  the  upper 
dorsal  and  lower  cervical  roots,  and  as  a  secondary  conse- 
quence ascending  degeneration  of  Goll's  columns. 

3.  Amyotrophic  lateral  Sclerosis. — This  is  a  peculiar  form 
of  sclerosis,  which  was  first  described  by  Charcot,  and 
is  distinguished  by  simultaneous  affection  of  the  lateral 
columns  of  the  cord  and  of  the  large  ganglionic  cells  of  the 
anterior  grey  cornua.  It  seems  almost  invariably  to  begin 
in  the  cervical  region  of  the  cord,  and  has  the  tendency  to 
spread  from  there  both  upwards  and  downwards.  The 
dorsal  and  lumbar  portions  are,  therefore,  gradually 
affected  in  the  same  manner,  and  the  disease  eventually 
creeps  upwards  towards  the  medulla  oblongata,  where  the 
motor  nuclei  are  found  sclerosed.  Charcot's  observations 
have  been  amply  confirmed  by  other  pathologists. 

In  a  case  which  has  recently  been  very  carefully  described 
by  Stadelmann,  the  crossed  pyramidal  columns  showed 
in  the  cervical  cord  numberless  oil-globules,  fewer  nerve- 
fibres  than  usual,  and  overgrowth  of  neuroglia.  The  direct 
cerebellar  columns  and  Tiirck's  columns  were  healthy.  In 
the  pyramidal  tracts  there  was  the  peculiar  "  pin-hole  " 
appearance  corresponding  to  perished  nerve-fibres,  the 
vacuum  being  filled  up  by  a  pale,  finely  granular  substance. 
In  the  anterior  cornua  was  at  the  same  time  found  great 


62  SCLEROSIS  OF  THE  SPINAL  COED. 

diminution  of  the  giant-cells,  more  especially  in  the  median 
and  antero-lateral  group,  while  in  the  intermedio-lateral 
tract  they  appeared  undiminished.  The  cells  which  still 
existed  in  the  anterior  cornua  were  either  shrunk  or 
swollen,  pigmented,  and  had  only  short  processes.  The 
anterior  roots  were  thin,  and  looked  wasted  ;  while  Clarke's 
vesicular  columns  were  normal. 

In  the  dorsal  cord  the  disease  of  the  crossed  pyramidal 
strands  was  much  more  severe.  There  were  very  few 
fibres  left  ;  the  oil-globules  and  pin-holes  were  abundant ; 
and  the  degeneration  extended  posteriorly  to  the  posterior 
columns  ;  while  also  the  antero-lateral  zone  and  the  whole 
of  Tiirck's  column  was  diseased.  The  anterior  cornua  were 
more  affected  than  in  the  cervical  cord,  while  in  the  lumbar 
cord  the  affection  was  much  less.  The  pyramidal  strands 
appeared  wasted  in  the  medulla  oblongata ;  the  grey 
matter  on  the  floor  of  the  fourth  ventricle,  including  the 
nuclei  of  the  hypoglossus  and  spinal  accessory  nerve, 
was  atrophied  ;  any  ganglionic  cells  which  still  existed 
appeared  either  shrunk  or  swollen,  pigmented,  and  almost 
devoid  of  protoplasmic  or  nerve-processes. 

4.  Insular  or  disseminated  Sclerosis  (Sclerosis  in  patches). 
— There  are  three  forms  of  this  disease,  viz.,  the  spinal, 
which  affects  different  areas  of  the  spinal  cord  ;  the  cere- 
hraly  which  invades  chiefly  the  motor  zone  of  the  brain  ; 
and  the  cerebrospinal,  in  which  the  two  former  affections 
occur  together.  The  merit  of  having  first  distinguished 
this  form  of  sclerosis  belongs  to  Vulpian,  and  more  parti- 
cularly to  Charcot  and  his  pupils. 

In  insular  sclerosis,  multiplication  of  nuclei  and  pro- 
liferation of  the  fibres  of  the  neuroglia  constitute  the 
initial  fact,  while  degenerative  atrophy  of  the  nerve-tubes 
is  consecutive  and  secondary. 

In  spinal  insular  sclerosis  the  patches  are  chiefly  found 
in  the  antero-lateral  columns,  but  they  may  exist  indis- 
criminately in  all  the  different  portions  of  the  cord,  whether 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     63 

white  or  grey.  The  patches  vary  in  size  and  shape  from 
that  of  a  millet-seed  to  a  pea  or  small  bean,  and  form  a 
striking  contrast  with  the  healthy  tissues  in  which  they  are 
imbedded.  They  have  the  same  grey  or  yellowish  colora- 
tion which  is  seen  in  the  long  bands  of  sclerosis  with 
which  we  have  become  familiar  as  affecting  entire  strands 
or  columns.  Where  there  is  much  proliferation  of  connec- 
tive tissue,  these  patches  may  be  slightly  elevated  over  the 
cut  surface,  while  when  there  has  been  much  shrinking 
there  is  a  corresponding  depression. 

As  far  as  their  microscopical  characters  are  concerned, 
Charcot  distinguishes  three  different  zones  in  these  patches, 
viz.,  1  st,  a  peripheral  zone,  in  which  there  is  overgrowth  of 
connective  tissue  and  wasting  of  the  myeline  sheath,  while 
the  axis-cylinder  is  either  normal  or  hypertrophied  ;  2nd, 
a  transition  zone,  in  which  the  medullary  sheath  has  dis- 
appeared, the  nerve-tubes  have  become  attenuated,  and  the 
axis-cylinder  enlarged  ;  and,  3rd,  a  central  zone,  in  which 
the  neuroglia,  with  the  myeline,  has  disappeared,  and  the 
axis-cylinder  is  reduced  in  size.  A  certain  number  of 
axis-cylinders,  however,  always  persist  in  the  otherwise 
completely  altered  tissue,  which  distinguishes  this  form  of 
sclerosis  from  all  others.  The  coats  of  the  blood-vessels  are 
thickened  ;  amyloid  bodies  are  found  interspersed  in  the 
fibrillary  tissue  ;  oil-globules,  which  constitute  the  debris  of 
the  destroyed  nerve-tubes,  are  plentiful  in  the  peripheral 
portions,  but  absent  in  the  central  zone,  where  the  morbid 
process  is  finished. 

Klein,  of  Moscow,  who  has  more  recently  investigated 
the  anatomy  of  this  disease,  finds  the  earliest  changes  in 
the  blood-vessels,  which  are  dilated  ;  the  perivascular 
spaces  contain  lymphoid  cells,  the  nuclei  of  the  neuroglia 
are  increased,  and  the  bulk  of  the  intertubular  substance 
appears  augmented.  Later  on  the  impaired  circulation 
in  the  altered  blood-vessels  and  undue  pressure  by  the 
new  cellular  elements  lead  to  degenerative  atrophy  of  the 


64  SCLEROSIS  OF  THE  SPINAL  CORD. 

nerve-tubes  and  nerve-cells.  Finally,  the  neuroglia  is 
replaced  by  sclerosed  connective  tissue,  with  occasional 
complete  occlusion  of  the  blood-vessels,  whereby  the  nutri- 
tion of  the  diseased  parts  is  still  further  affected. 

It  would,  therefore,  appear  that  at  least  in  some  forms 
of  insular  sclerosis  there  is  an  analogous  change  in  the 
blood-vessels  of  the  affected  parts  as  that  which  has  been 
described  by  Ordonez  and  Be  van  Lewis  as  occurring  in 
certain  forms  of  tabes.  This  seems  also  to  be  the  opinion 
of  Bastian,-^  who  has  found  the  walls  of  the  capillaries, 
arteries,  and  veins  greatly  thickened,  more  especially  the 
adventitia,  and  has  seen  this  overgrowth  to  extend  inwards 
so  as  to  cause  fibroid  degeneration  of  the  middle  and  inner 
coat  of  the  vessel  (endo-arteritis).  Without  committing 
himself  to  a  definite  opinion  whether  the  process  com- 
mences in  the  neuroglia  or  the  blood-vessels,  Bastian 
agrees  with  other  observers  in  thinking  that  in  this  form  of 
sclerosis  the  changes  in  the  neuroglia  are  primary,  and 
those  in  the  nerves  secondary ;  while  in  the  bands  of 
secondary  degeneration  the  nerves  suffer  primarily,  and 
the  neuroglia  subsequently. 

The  patches  of  primary  insular  sclerosis  do  not  ap- 
pear to  conduce  to  any  secondary  degenerations,  either 
ascending  in  G-oll's  columns,  or  descending  in  the  antero- 
lateral columns.  Most  probably  the  reason  of  this  lies  in 
the  peculiar  anatomical  character  of  the  lesion,  as,  through 
the  persistence  of  the  axis -cylinder,  the  nervous  influence 
is  not  entirely  cut  off  between  the  fibres  and  their  trophic 
centres.  We  should  therefore  expect  to  find  any  secondary 
degeneration  only  in  very  far-advanced  cases  of  insular 
sclerosis. 

5.  Of  other  combined  system-diseases  of  the  spinal  cord 
our  knowledge  is  as  yet  very  rudimentary.  Kahler  and 
Pick  have  described  cases  where  the  pyramidal  strands, 
the    direct    cerebellar  strands,   and    Goll's  columns  were 

'  Loc.  elL,  p.  1490. 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     65 

diseased  ;  and  Striimpell  has  recorded  some  in  which  the 
patients  showed  during  life  the  symptoms  of  amyotrophic 
lateral  sclerosis,  and  in  whom  there  were  found  after 
death  combined  degeneration  of  the  pyramidal  strands,  a 
portion  of  the  posterior  columns,  the  direct  cerebellar 
strands,  and  atrophy  of  cells  in  Clarke's  vesicular  columns. 
The  white  strands  just  mentioned  are  evolutionally  dis- 
tinguished by  late  formation  of  the  myeline  sheaths.  In 
this  affection  there  is  also  no  transverse  spreading  of  the 
disease,  and  each  system  is  independently  affected,  as 
shown  by  different  degrees  of  intensity  of  the  affection  in 
each,  while  the  symmetrical  character  is  fully  sustained. 
As  regards  the  posterior  column,  it  appears  that  just  those 
parts  are  affected  which  escape  in  the  earlier  stages  of 
tabes,  viz.,  the  body  of  Goll's  columns,  the  small  round 
field  at  the  anterior  end  of  the  anterior  area,  and  the  pos- 
tero-external  field  (2,  3,  and  o  in  Fig.  3)  in  Burdach's 
columns. 

Friedreich^  in  1863  drew  attention  to  a  peculiar  form  of 
the  disease  to  which  he  and  others  have  applied  the  term 
hereditary  ataxy.  This  name,  however,  appears  to  be  an 
unsuitable  one,  as  it  seems  to  imply,  first,  that  the  disease 
usually  known  as  tabes  or  ataxy  is  not  hereditary  ;  and, 
second,  that  the  disease  which  Friedreich  described,  both 
clinically  and  pathologically,  is  identical  with  Romberg's 
tabes  dorsalis  or  Duchenne's  ataxie  locomotrice.  Such, 
however,  is  not  the  case,  as  hereditary  influence  is  not 
altogether  wanting  in  ordinary  tabes,  and  the  malady  first 
described  by  Friedreich  differs  in  so  many  essential  points 
from  ordinary  tabes  that  we  now  consider  the  two  affections 
to  be  quite  distinct. 

The  cases  originally  recorded  by  Friedreich,  were  not 
such  of  direct  transmission  of  a  peculiar  form  of  spinal 
disease  from  parents  to  children,  but  instances  of  a  malady 

^  Virchow's  "  Archiv,"  vol.  xxvi.  and  xxvii.,  1863  ;  vol.  Ixviii.  and 
Ixx.,  1877  and  1878. 

P 


66  SCLEROSIS  OF  THE  SPINAL  CORD. 

occurring  in  brothers  and  sisters  whose  parents  had  been 
free  from  it.  The  term  "  hereditary  tabes  "  is  therefore  a 
misnomer.  "  Family  ataxy,"  although  more  correct,  does 
not  sound  well  ;  and  under  these  circumstances  we  may 
provisionally  call  the  malady  in  question  Friedreich'' s 
disease,  which  has  the  advantage  of  not  committing  us  to 
any  special  pathological  theory. 

The  pathological  lesions  in  Friedreich's  disease  show  a 
greater  variety  of  degenerative  changes  than  those  which 
are  habitually  discovered  in  ordinary  tabes.  There  is  not 
only  posterior  lepto-meningitis  and  sclerosis  in  Goll's  and 
Burdach's  columns  ;  but  the  lateral  columns,  Clarke's 
vesicular  columns,  the  central  grey  matter,  and  even  the 
anterior  columns  are  found  sclerosed.  In  ^q  medulla 
oblongata  the  sclerosis  extends  to  the  posterior  pyramids 
and  the  floor  of  the  fourth  ventricle,  involving  the  nuclei 
and  trunks  of  the  hypoglossal  nerves.  The  posterior  roots 
have  generally  been  found  wasted  and  indurated,  and  the 
brachial,  crural,  and  sciatic  nerves  in  a  state  of  atrophy. 

Friedreich's  disease,  therefore,  appears  to  be  a  diffuse 
sclerosis  of  different  portions  of  the  spinal  cord  and 
medulla  oblongata,  and  clinically  as  well  as  pathologically 
distinct  from  tabes  and  from  insular  sclerosis.  It  is  hardly 
worth  while  to  discuss  seriously  Hammond's  opinion,  that 
the  disease  begins  in  the  bulb,  and  afterwards  invades 
the  cerebellum  ;  for  we  shall  see  further  on  that  clinical 
observation  shows  it  to  commence  in  the  lumbar  enlarge- 
ment of  the  cord,  while  pathological  anatomy  has  shown 
the  cerebellum  to  be  healthy  even  after  the  affection  had 
lasted  upwards  of  thirty  years.  The  complete  collapse 
of  Duchenne's  first  theory  of  locomotor  ataxy  being  a  cere- 
bellar disease  might  have  prevented  Hammond  from  once 
more  bringing  the  cerebellum  forward  in  connection  with 
the  pathology  of  a  similar  complaint. 

6.  Finally,  it  has  been  shown  that  there  is  such  a  thing 
as  pseudo-sclerosis.     There  may  be  clinically  all  the  symp- 


MORBID  ANATOMY  OF  OTHER  FORMS  OF  SCLEROSIS.     67 

toms  of  sclerosis  of  the  lateral  columns,  or  of  insular 
sclerosis,  yet  no  lesion  is  discovered  after  death.  In 
hysterical  girls,  Miiller  of  Gratz,  and  my  colleague,  Hughes 
Bennett,  have  drawn  attention  to  this  occurrence  of  pseudo- 
lateral  sclerosis,  and  Westphal  has  recently  seen  two  cases 
of  pseudo-insular  sclerosis  without  anatomical  lesion :  one 
of  these  patients  was  a  lad,  who  began  to  show  signs  of 
motor  debility  in  the  upper  and  lower  extremities,  and 
double  vision  at  the  age  of  eighteen  ;  six  years  later  he 
became  imbecile  ;  there  was  tremor  in  both  upper  and 
lower  extremities  attending  any  voluntary  movements,  and 
the  phenomenon  known  as  paradoxical  contraction  ;  tremor 
was  also  seen  in  the  head,  tongue,  and  lower  jaw  ;  the 
speech  was  drawling,  and  all  movements  were  slow  and 
clumsy.  Three  years  afterwards  the  patient  died,  and  all 
parts  of  the  nervous  system  were  found  to  be  healthy. 
Some  time  ago  I  had  a  girl  under  my  care  at  the  hospital, 
who  had  been  bedridden  for  three  years  previous  to  her 
admission,  and  who  on  examination  showed  all  the  symp- 
toms of  primary  lateral  sclerosis.  Three  months  after- 
wards she  left  the  hospital  nearly  well,  and  it  therefore 
became  quite  evident  that  no  structural  lesion  had  existed, 
but  that  the  case  had  been  one  of  pseudo-lateral  sclerosis. 


f2 


68  SCLEROSIS  OP  THE  SPINAL  CORD. 


CHAPTER  V. 

ETIOLOaY. 

That  certain  poisons,  when  habitually  taken  into  the 
system,  may  lead  to  sclerosis  of  certain  portions  of  the 
spinal  cord,  cannot  be  disputed.  It  has  long  been  known 
that  a  peculiar  form  of  spinal  debility  is  caused  by  eating 
bread  mixed  in  imdue  proportions  with  ergot  of  rye,  the 
permanent  mycelium  or  sclerotium  of  a  fungus  of  the  family 
of  the  pyrenomycetes,  which  grows  on  the  flower  and  fruit 
of  secale  cereale,  and  which  contains,  according  to  the 
researches  of  Dragendorff  and  Podwissotzki,  two  active 
principles,  viz.,  sclerotinic  acid  (about  4*5  per  cent.)  and 
a  colloid  substance  termed  sclero-mucine  (from  2  to  3  per 
cent.).  The  term  ergotine,  which  was  first  introduced  by 
Wiggers,  and  afterwards  used  by  Bonjean  and  Wenzell, 
had  better  be  avoided,  as  very  different  substances  are 
comprehended  by  it  ;  and  it  is  by  no  means  proved  that 
what  is  called  ergotine  really  constitutes  the  active  prin- 
ciple of  ergot.  Even  less  is  known  of  other  alkaloids  said 
to  be  contained  in  the  mycelium,  viz.,  ergotinine  and 
ecboline.  Sclerotinic  acid,  however,  is  a  definite  poison, 
five  grains  of  which  will  kill  a  kitten,  while  ten  grains 
prove  fatal  to  a  rabbit.  The  phenomena  produced  by  the 
administration  of  this  substance  are,  according  to  Nikitin, 
paralysis,  lowering  of  the  temperature  of  the  body,  and 
retarded  respiration,  which  latter  ceases  before  the  heart's 
action  is  arrested.  Tuczek  has  endeavoured  to  produce 
tabes  artificially  by  feeding  animals  with  small  doses 
of    ergot  and  sclerotinic   acid.      Under   the   influence  of 


ETIOLOGY.  69 

ergot,  mice  and  fowls  died  rapidly,  with  symptoms  of 
wasting  and  fatty  degeneration  of  the  principal  organs. 
Rabbits,  on  the  other  hand,  appeared  to  be  insusceptible  to 
the  action  of  the  poison,  since  they  remained  perfectly  well 
when  fed  for  months  with  doses  varying  from  half  an 
ounce  to  an  ounce.  Cats  and  dogs,  again,  wasted  away, 
became  unsteady,  more  especially  in  the  hind  legs  ;  but  the 
knee-jerk  persisted,  and  after  death  no  change  in  the  spinal 
cord  was  discovered.  Sclerotinic  acid  in  small  doses  pro- 
duced, according  to  the  same  observer,  more  distinctly  the 
phenomena  of  locomotor  ataxy,  first  in  the  hind-legs  and 
afterwards  in  the  fore-legs  ;  but  the  knee-jerk  could  be 
elicited  to  the  last,  and  inspection  of  the  cord  showed 
that  organ  to  be  unaffected.  Experiments  made  with  tri- 
methylamin  have  likewise  given  uncertain  data. 

While,  therefore,  the  results  of  purely  experimental  path- 
ology are  ambiguous,  and  so  far  bear  out  Vulpian's  state- 
ment made  some  years  ago,  that  it  is  impossible  to  produce 
tabes  artificially  in  animals,  it  is  certain  that  when  bread 
contaminated  with  ergot  of  rye  is  habitually  taken  as  food, 
posterior  sclerosis  becomes  developed.  Until  lately  the 
description  of  the  symptoms  which  occurred  in  such  cases 
has  been  somewhat  obscure,  and  the  results  of  inspection 
not  sufiiciently  clear;  but  recently  Tuczek  has  given  a  lucid 
description  of  an  epidemic  of  this  kind,  which  occurred  in 
the  district  of  Frankenberg  (Hesse)  subsequently  to  the  bad 
harvest  of  1879,  when  as  much  as  ten  per  cent,  of  ergot  of  rye 
was  found  to  be  mixed  with  the  flour  of  which  the  bread 
supplied  to  the  inhabitants  was  made.  The  district  men- 
tioned contains  twelve  villages,  with  a  population  of  2,500  ; 
five  hundred  of  the  latter  fell  ill,  many  of  whom  were 
children.  The  common  people  there  are  miserably  poor  ; 
the  dwellings  and  the  food  are  generally  abominable  ;  and, 
in  addition  to  this,  the  people  have  an  extraordinary  prone- 
ness  to  dram-drinking,  for  on  the  average  three  quarts  of 
raw  potato-spirit  are  consumed  daily  by  eacli  person,  and 


70  SCLEROSIS  OF  THE  SPINAL  CORD. 

even  children  are  found  addicted  to  this  pernicious  habit. 
The  harvest  of  1880  contained  much  less  ergot  of  rye  than 
the  one. .of  1879,  and  does  not  appear  to  have  led  to  any- 
fresh  outbreaks  of  the  malady  ;  yet  it  gave  rise  to  many 
relapses ';  and  although  the  harvest  of  '81  was  good,  and 
the  meal  pure,  cases  nevertheless  occasionally  presented 
themselves  even  then  for  admission  into  the  hospital, 
owing  to  relapses. 

In  some  few  instances  the  action  of  the  poison  appeared  to 
be  rapid,  since  severe  cerebro-spinal  symptoms  were  observed 
soon  after  the  ingestion  of  the  poisonous  bread.  In  by  far 
the  largest  majority  of  cases,  however,  the  mental  affection, 
as  well  as  the  epilepsy  and  tabes,  broke  out  some  months 
afterwards,  and  in  some  instances  ergotism  set  in  a  con- 
siderable time  after  the  consumption  of  the  bread  had  been 
discontinued. 

This  seems  to  show  that  there  is,  apart  from  the  primary 
affection,  a  kind  of  secondary  or  late  intoxication — 
resembling  somewhat  the  progress  of  syphilis — and  leading 
eventually  to  severe  disease  of  the  centres  of  the  nervous 
system.  Seventeen  patients  suffering  from  ergotinic  tabes 
were  received  into  the  University  Hospital  of  Marburg, 
eleven  being  males  and  six  females,  including  six  children 
under  fifteen  years  of  age.  There  were  other  cases  in  which 
attacks  of  mania,  with  epileptiform  seizures,  formed  the 
principal  symptoms  ;  yet  in  all  cases  without  exception 
the  knee-jerk  was  absent,  and  eventually  returned  only  in 
a  single  instance,  although  a  good  many  cases  recovered. 
Even  in  children,  in  whom,  as  a  general  rule,  the  patellar 
reflex  is  so  well  marked,  it  could  not  be  elicited  after  they 
had  shown  symptoms  of  ergotism. 

In  the  cases  of  tabes,  numbness,  pins  and  needles, 
lightning-pains,  a  feeling  of  constriction  round  the  waist, 
analgesia,  staggering  on  closing  the  eyes,  and  ataxy  of 
gait  were  present.  The  faradic  sensibility  was  much 
diminished  ;  and  the  faradic  wire   brush    applied  with  a 


ETIOLOGY.  71 

powerful  current  caused  hardly  any  reddening  of  the  skin. 
The  pupils  were  large,  as  is  often  seen  in  the  commence- 
ment of  tabes-:  In  four  fatal  cases  Burdach's  columns 
were  found  sclerosed,  while  Goll's  columns  appeared  to  be 
either  normal  or  only  slightly  affected.  The  antero-lateral 
columns  and  the  grey  matter  were  healthy.  In  Burdach's 
columns  the  degeneration  could  be  traced  throughout  the 
entire  extent  of  these  tracts,  from  the  lumbar  portion  up  to 
the  medulla  oblongata.  The  pia  spinalis  was  found  to  be 
healthy.  The  changes  in  the  cord  consisted  essentially  of 
overgrowth  of  the  neuroglia  and  atrophy  of  nerve-fibres. 
There  were  no  traces  of  acute  myelitis  anywhere.  Cor- 
pora amylacea  were  present. 

The  absence  of  the  knee-jerk  was  of  the  greatesjt  dia- 
gnostic value  in  all  these  cases.  In  some,  where  at  first  only 
epileptic  seizures  or  mental  symptoms  were  present,  this 
symptom  justified  the  conclusion  that  there  was  even  then 
a  definite  anatomical  alteration  in  the  posterior  columns  of 
the  cord.  In  one  of  these  patients  absence  of  the  knee- 
jerk  was  the  only  sign  of  tabes,  and  yet  the  inspection 
showed  that  even  at  such  an  early  stage  there  was  decided 
evidence  of  degenerative  atrophy  in  the  cord„  The  blood- 
vessels and  the  pia  mater  were  healthy,  and  so  were  the  pos- 
terior roots  and  spinal  ganglia  ;  but  in  the  lumbar  and  lower 
dorsal  cord  the  whole  transverse  section  of  Burdach's  column 
was  found  to  be  diseased;  further  upwards  only  the  middle 
portion  of  this  system  appeared  to  have  suffered,  while  in 
the  cervical  cord  only  a  small  tract  contiguous  to  G-oll's 
column  was  found  in  a  state  of  sclerosis. 

A  counterpart  to  ergotism  is  seen  in  the  causation 
of  spastic  spinal  paralysis,  with  presumably  sclerosis 
of  the  pyramidal  strands  of  the  cord,  by  eating  bread 
mixed  with  the  meal  of  the  grain  of  Lathyrus  Cicera. 
This  bread  is  consumed  by  the  poorest  classes  in  Upper 
and  Central  India,  especially  near  Allahabad  and  in  Upper 
Scinde,  in  Algeria,   in   some  parts  of  France,  and  in  the 


72  SCLEROSIS  OP  THE  SPINAL  COKD. 

south  of  Italy,  where  the  people  call  it  *'  mochi.'* 
Hippocrates  and  Galen  speak  of  crurum  im2ootenUa  in 
those  who  fed  on  ervum,  which  is  analogous  to  Lathyrus. 
Targioni-Tozzetti  observed  an  epidemic  of  this  disease? 
which  he  called  '^  epidemia  di  storpio  "  (cripple-plague),  in 
the  last  century.  In  1873,  Professor  Cantani,  of  Naples, 
proposed  to  call  it  Lathyrism,  in  order  to  point  out  its 
analogy  with  ergotism.  It  was,  however,  Brunelli,^  of 
E-ome,  who  recognised  that  the  peculiar  affection  caused 
by  eating  Lathyrus  shows  the  symptoms  of  spastic  spinal 
paralysis.  He  happened  to  see,  in  October,  1880,  five 
cases  of  this  kind,  and  found  that  all  the  patients  had  come 
from  the  commune  of  Alatri,  near  Eome  ;  they  were 
small  farmers,  three  of  whom  belonged  to  the  same 
family  ;  and  they  had  for  several  months  been  obliged  to 
subsist  on  bread  consisting  of  equal  parts  of  rye  and 
Lathyrus.  Proceeding  to  Alatri,  Brunelli  found  six  more 
persons  similarly  affected.  Most  of  them  were  young 
men  under  thirty-five  years  of  age.  The  aged  and  the 
children  who  partook  of  the  same  bread  did  not  appear  to 
suffer.  In  that  part  of  the  country  the  disease  had  not 
been  known  before  1875,  when  a  large  quantity  of  Lathyrus 
grain  had  been  imported  and  sold  at  a  very  low  price. 

The  first  symptom  of  illness  consisted  of  debility  and 
tremor  in  the  legs  ;  the  patients  had  the  appearance  of  being 
drunk,  more  especially  after  meals  taken  when  the  Lathyrus 
bread  had  been  the  only  food.  If  the  use  of  the  bread 
was  then  discontinued,  the  people  got  quite  well  again  ; 
but  in  those  whom  poverty  obliged  to  go  on  with  it  for 
any  length  of  time  the  disease  made  rapid  progress,  and 
after  two  or  three  months  presented  the  characteristic 
aspect  of  spastic  paralysis.  There  was  great  stiffness  in 
the  legs,  and  impaired  power  of  walking  ;  the  steps  were 
short,  and  the  feet  dragged  on  the  ground  ;  the  legs  were 

*  "Transactions  of  the  International  Medical  Congress,"  London^ 
1881.    Vol.  ii.,  p.  45. 


ETIOLOGr.  73 

approached  to  one  another  by  rigidity  of  the  adductors  of 
the  thighs  ;  the  toes  were  contracted  in  flexion,  and  the 
heels  lifted  from  above  the  ground  by  contraction  of  the 
gastrocnemii.  Those  most  affected  seemed  when  sitting 
riveted  to  the  chair,  and  could  only  get  up  after  repeated 
efforts.  Crutches  and  ordinary  walking-sticks  were  of 
little  use  to  them  ;  but  they  got  on  better  with  a  long  sort 
of  an  alpenstock,  of  which  they  grasped  the  upper  end 
with  both  hands.  Muscular  nutrition  was  not  impaired  ; 
there  was  no  affection  of  sensibility  or  of  the  special 
senses,  the  sphincters,  or  the  brain.  The  tendon  re- 
flexes were  exaggerated,  more  particularly  as  regards  the 
rapidity  with  which  the  leg  was  jerked  forward  on  per- 
cussing the  patellar  tendon,  and  less  so  with  regard  to  the 
extent  of  the  movement  produced. 

It  has  been  noticed  in  Italy  that  pigs,  after  feeding  on 
the  fresh  plant  of  Lathyrus  Cicera  begin  presently  to  drag 
their  hind  legs.  The  dried  grain  of  the  same  plant,  when 
taken  by  pigs,  dogs,  and  rabbits,  causes  similar  effects. 
Rabbits  seem  to  die  soon  after  they  have  been  fed  on  it, 
while  hogs  resist  the  action  of  the  poison  much  longer. 
Lathyrism  is  by  some  authors  believed  to  be  identical  with 
beri-beri,  but  recent  researches  seem  to  make  it  probable 
that  the  paraplegia  of  beri-beri  is  not  owing  to  spinal  dis- 
ease, but  to  acute  multiple  neuritis. 

Mr.  Barron,  of  Liverpool,  has  given  me  an  interesting 
account  of  an  epizootic  in  horses  which  lately  occurred 
in  that  city,  owing  to  their  having  been  fed  on  Indian 
mutters,  which  are  supposed  to  be  the  seeds  of  Lathyrus 
sativus.  A  team -owner  began  feeding  his  horses,  which 
were  seventy-eight  in  number,  and  amongst  which  there 
were  four  ponies,  on  mutters  in  the  beginning  of  October  last. 
They  remained  apparently  well,  although  the  men  com- 
plained of  slowness  of  the  lateral  movements  of  the  horses 
in  stables  and  difficulty  in  backing.  To  this,  however,  no 
attention  was  paid  until  the  end  of  March  last,  when  the 


74  SCLEROSIS  OF  THE  SPINAL  CORD. 

weather  was  cold  and  damp,  with  easterly  winds.  At  this 
time  a  horse  was  seized  with  laryngeal  spasm  in  the 
street,  and  fell  dead  from  asphyxia.  Nine  others  have 
since  died,  with  the  same  symptoms  ;  and  in  all  thirty- 
three  have  been  affected, — no  ponies,  and  only  one  mare. 
In  one  horse  tracheotomy  was  performed  for  the  laryn- 
geal spasm.  Mr.  Barron  has  as  yet  had  but  one  post- 
mortem examination,  in  which  he  was  unable  to  get  the 
medulla  oblongata,  but  found  complete  atrophy  of  the  left 
recurrent  laryngeal  nerve  and  the  muscles  supplied  by  it ; 
no  apparent  wasting  of  other  muscles  ;  but  this  remained 
doubtful,  as  microscopic  examination  of  the  right  re- 
current nerve  and  the  muscles  animated  by  it  showed  a 
commencement  of  atrophy.  He  also  found  wasting  of 
the  motor  cells  of  the  anterior  cornua  of  the  cord,  which 
was  most  marked  in  the  left  side,  with  sclerosis  of  the 
corresponding  crossed  pyramidal  strand. 

It  would  be  interesting  to  ascertain  in  future  observa- 
tions of  this  kind  whether  it  is  chiefly  or  exclusively  the 
abductors  of  the  vocal  cords  which  are  affected,  and 
whether  the  adductors  remain  healthy  or  are  contracted. 
Laryngeal  "  crises "  with  fatal  results  have  occurred  in 
patients  affected  with  tabes,  but  their  occurrence  in  spastic 
spinal  paralysis  is  problematical.  An  examination  of  the 
patellar  tendon  reflexes  in  the  suffering  horses  would  show 
whether  the  disease  from  which  they  suffered  partook 
more  of  lateral  or  of  posterior  sclerosis  ;  but  the  wasting 
of  the  ganglionic  cells  of  the  anterior  cornua  of  the  cord, 
which  Mr.  Barron  discovered,  goes  some  way  to  show 
that  it  may  have  been  that  form  of  spinal  disease  which  is 
known  as  amyotrophic  lateral  sclerosis. 

I  now  proceed  to  consider  the  influence  of  another 
poison  which  is  far  more  subtle  in  its  nature,  more  widely 
diffused  over  the  earth,  and  more  destructive  of  human 
life  and  happiness  in  its  effects  than  any  other,  viz.,  the 
poison  of  syphilis.     Syphilis^    which    begins    as  a   blood- 


ETIOLOGY.  75 

disease,  and,  if  "unchecked  in  its  course,  ends  as  a  flesh-and- 
blood  disease,  has  long  been  known  to  play  an  important 
part  in  the  production  of  certain  diseases  of  the  brain,  such 
as  tumour,  arterial  thrombosis,  and  meningo-encephalitis. 
It  is,  however,  only  quite  recently  that  evidence  has  been 
brought  forward  from  different  quarters  showing  that  it 
lies  at  the  root  of  most  cases  of  tabes  which  come  under 
our  observation  in  practice  ;  and  I  have  no  doubt  that  it 
will  presently  be  found  to  have  likewise  a  direct  or  indirect 
influence  in  the  causation  of  other  forms  of  primary 
sclerosis  of  the  cord.  For  practical  medicine  this  is  one 
of  the  most  important  facts  which  have  been  elicited  by 
recent  researches,  as  it  seems  to  open  up  to  us  a  new 
prospect  of  our  being  able  by  energetic  and  long-continued 
treatment  of  the  venereal  distemper  to  prevent  the  out- 
break of  tabes  in  many  instances,  and  to  cure  it,  if  the 
patient  comes  under  care  in  the  initial  stage  of  the  malady. 
When  it  once  becomes  known  throughout  the  profession 
that  insufficient  treatment  of  the  earliest  symptoms  of 
venereal  disease  opens  the  door  to  the  invasion  of  such 
an  awful  disease  as  tabes,  which  causes  the  most  severe 
sufferings  that  men  are  called  upon  to  endure,  and  which 
when  fully  established  baffles  all  our  therapeutical 
resources,  it  may  surely  be  hoped  that  the  treatment 
of  primary  syphilis,  and  of  the  earlier  stages  of  secondary 
syphilis,  will  be  carried  out  in  a  more  systematic  manner 
than  is  now  frequently  the  case,  and  that  every  trouble  will 
be  taken  to  destroy  that  baneful  and  insidious  poison  of 
syphilis  before  it  has  taken  a  thorough  hold  of  the  system. 
Instead  of  telling  the  patient,  as  is  now  often  done,  that 
his  primary  affection  is  ''  nothing,"  and  "  will  soon  be 
well,"  his  attention  should  be  drawn  to  the  necessity  of  a 
long  and  persevering  treatment,  if  he  values  his  health  and 
happiness  ;  and  he  should  be  plainly  advised  that  it  is  very 
often  in  cases  which  have  a  mild  beginning  that  years 
afterwards  the  most  terrible  consequences  are  apt  to  super- 


76  SCLEROSIS  OF  THE  SPINAL  CORD. 

vene.  We  fortunately  possess  specific  antidotes  to  the 
syphilitic  poison  in  mercury  and  iodide  of  potassium  ;  but 
these  can  only  exert  their  full  effects  if  perseveringly  used 
for  many  months  from  the  very  beginning  of  the  malady. 
Thus  only  can  we  eventually  succeed  in  preventing  the 
evolution  of  some  of  the  direst  diseases  to  which  the  human 
species  is  liable. 

The  earlier  observers  of  tabes  did  not  recognise  the 
connexion  between  that  malady  and  the  venereal  poison. 
Thus  we  find  that  Romberg, ^  that  sagacious  physician,  to 
whose  clinical  acumen  we  owe  the  first  and  truly  masterly 
description  of  the  more  prominent  symptoms  of  the  disease, 
when  discussing  the  causes  of  tabes,  does  not  say  a  single 

about  syphilis.  Duchenne,^  many  years  afterwards,  noticed 
that  several  of  his  patients  had  had  syphilis,  and  that  this 
appeared  to  be  the  only  rational  or  obvious  cause  of  the 
ataxy  ;  but  he  added  that  such  a  conclusion  was  hazardous, 
inasmuch  as  there  was  no  novel  or  special  symptom  in  those 
cases,  apart  from  certain  well-known  signs  of  the  venereal 
distemper.  It  is  true  that  the  pain  complained  of  appeared 
occasionally  to  be  more  severe  or  was  only  felt  at  night, 
but  this  also  happened  when  there  was  no  syphilis  ;  while 
with  regard  to  treatment,  anti-syphilitic  remedies  had  no 
beneficial  influence  on  the  disease.  Fournier  was  the  first 
who,  in  1876,  expressed  himself  decidedly  for  the  syphilitic 
origin  of  tabes,  and  has  more  recently  developed  his  ideas 
fully  in  a  work^  which,  although  written  in  the  spirit  of  a 
special  pleader,  contains,  nevertheless,  a  large  amount  of 
irrefutable  evidence  establishing  his  thesis.  He  was  fol- 
lowed in  France  by  Vulpian,^  who  placed  syphilis  in  the 
first  rank  of  those  influences  which  determine  the  outbreak 

*  "Lehrbuch  der  Nervenkrankheiten,"  Eerlin,  1840. 

2  "  De  1' Electrisation  Localisee,  etc.,"  p.  655.     3rd  Edition.     Paris, 
1872. 

3  "De  I'Ataxie  Locomotrice  d'origine  syphilitique."     Paris,  1882. 

*  "  Maladies  du  Systeme  Nerveux,"  p.  245.     Paris,  1879. 


ETIOLOGY.  77 

of  the   malady,   and  asserted  that  there  are  few  patients 
suffering  from  tabes  who  have  not,  a  few  years   before  the 
appearance  of  the  first  symptoms,  had  an  infecting  sore  and 
secondary  syphilitic  manifestations  ;  that  a  few  of  these 
have  been  properly  treated,  but  most   of  them  very  insuffi- 
ciently   so ;  and  that    amongst   twenty    patients   suffering 
from  tabes  there  were  at  least  fifteen  who  had  previously 
been  syphilitic.     Caizergues,^  who  has  reported  a  hundred 
cases  of  syphilitic  affections  of  the  cord  observed  by  various 
authors  and  himself,  has  from  his  own  experience  recorded 
three  cases    of  undoubted  syphilitic  tabes.     Grasset^    has 
recently  made  the  inspection  of  one  of  these  latter  cases, 
and    found    in    the    brain    diffuse    lesions    of    meninofo- 
encephalitis,  and  in  the  cord  systematic  sclerosis,  which, 
below  the  cervical  enlargement,  affected  the  whole  of  the 
posterior  columns,  and,  above  that  point,  only  Goll's  columns. 
In  that  case    the  ataxy  had  been  confined  to  the  lower 
extremities,  but  the  patient  had  also  suffered  from  general 
paralysis  (megalomania).     According  to  him,  the  circum- 
stance that  syphilis  habitually  produces  diffuse  lesions  in 
the  brain  does  by  no  means  show  that  it  could  not  produce 
systematic  lesions  in  the  cord ;  and  he  is  of  opinion  that 
clinical  evidence  should,  as  far  as  this  point  is  concerned, 
be  held  of  greater  weight  than  pathological  anatomy. 

In  this  country,  Moore,  Dreschfeld,  Drysdale,  Gowers, 
Hutchinson,  and  others  have  expressed  themselves  in 
favour  of  the  syphilitic  origin  of  the  disease  in  the  majority 
of  cases. 

A  few  years  ago  it  occurred  to  me  ^  that  it  would  be 
worth  while  to  ascertain  the  influence  of  syphilis  in  the 
production  of  other  diseases  of  the  nervous  system,  and  to 

»  "  Des  Myelites  Syphilitiques,"  p.  72.     Montpellier,  1878. 

^  "  Traito  Pratique  des  Maladies  du  Systeme  Nerveux,"  p.  1017. 
2nd  Edition.     Montpellier,  1881. 

3  "The  Lancet,"  1881,  vol.  ii.,  p.  496  ;  and  "Transactions  of  the 
International  Medical  Congress,"  1881,  vol.  ii.,  p.  38. 


78  SCLEROSIS  OF  THE  SPINAL  CORD. 

compare  the  numbers  thus  obtained  with  those  which  had . 
already  been  recorded  for  tabes.  In  this  way  a  kind  of  cross- 
experiment  would  be  made  whereby  I  thought  that  a  good 
deal  of  light  might  be  thrown  upon  this  question.  I  there- 
fore analysed  a  thousand  consecutive  cases  of  nervous 
affections  recorded  in  my  case-books  with  regard  to  this 
point,  without  making  the  least  attempt  at  selection. 

Amongst  these  there  were  206  of  epilepsy ;  101  of 
neurasthenia,  without  evidence  of  substantial  lesions  of 
the  nervous  system  ;  77  of  hemiplegia  owing  to  cere- 
bral haemorrhage  or  softening  ;  51  of  neuralgia  ;  and  32 
cases  of  tabes  with  fully  developed  symptoms  ;  the  re- 
mainder were  cases  of  hysteria,  infantile  paralysis,  local 
paralysis,  muscular  atrophy,  anaesthesia,  chorea,  tumour 
of  the  brain,  impotency,  paralysis  agitans,  torticollis,  etc. 
It  then  appeared  that  in  29  out  of  the  32  cases  of  ataxy 
there  was  a  syphilitic  history  ;  and  in  these  29,  secondary 
symptoms  had  occurred  in  28,  while  in  one  of  them 
there  had  been  a  soft  chancre  and  a  bubo,  but  no 
secondaries. 

This  shows  a  percentage  of  90*6  in  favour  of  the  syphi- 
litic origin  of  tabes,  which  appears  exceedingly  high  when 
compared  with  the  percentages  found  for  other  nervous 
affections,  inasmuch  as  of  206  cases  of  epilepsy  only  10, 
of  101  cases  of  neurasthenia  only  12,  of  77  cases  of 
hemiplegia  5,  and  of  51  cases  of  neuralgia  only  2,  had 
been  preceded  by  syphilis.  The  percentages  are,  there- 
fore, as  follows  : — 

Tabes  was  preceded  by  syphilis  in  90*6  per  cent. 
Neurasthenia     „  „  11  "8         „ 

Hemiplegia        „  „  6'2         „ 

Epilepsy  „  „  4-8         „ 

Neuralgia  „  „  3'9         „ 

There  were  six  additional  cases  in  which  paralysis  of 
the  ocular  muscles,  shooting  pains,  and  sexual  debility 
rendered  it  probable  that  sclerosis  was   developing  in  the 


ETIOLOGY.  79 

posterior  columns  of  the  cord,  and  in  four  of  these  there 
were  sjphiHtic  antecedents.  These  cases,  however,  were 
lost  sight  of  before  the  symptoms  had  become  unequivocal ; 
and,  as  thej  all  occurred  some  time  before  the  loss  of  the 
patellar  tendon-reflex  was  utilised  for  the  diagnosis  of  this 
disease,  I  think  it  better  to  exclude  them.  Yet  it  is  a  sig- 
nificant fact  that  in  four  out  of  these  six  doubtful  cases 
syphilis  should  have  previously  occurred. 

With  regard  to  the  interval  which  had  elapsed  between 
the  first  symptoms  of  syphilis  and  of  tabes,  it  was  found 
that  the  former  had  preceded  the  latter  upwards  of  twenty 
years  in  two  cases,  between  ten  and  twenty  years  in  seven 
cases,  between  two  and  ten  years  in  nineteen  cases,  and 
eighteen  months  in  one  case.  Amongst  the  three  cases  in 
which  there  was  no  history  of  syphilis,  the  affection  was 
attributed  in  one  to  an  operation  for  piles,  in  another  to  an 
accident  in  a  tramcar,  and  in  a  third  to  exposure  to  wet 
and  cold.  The  age  at  which  tabes  became  developed  was 
from  twenty-one  to  forty-five,  and  all  the  patients  were 
males.  In  all  cases,  some  other  cause,  such  as  accidents, 
over-exertion,  the  influence  of  wet  and  cold,  and  sexual  or 
alcoholic  excesses,  were  mentioned  as  having  led  to  the 
outbreak  of  the  complaint. 

Since  taking  these  percentages  I  have  had  thirty-four 
new  cases  of  fully  developed  tabes  under  my  care  in  pri- 
vate practice. ■•■  Amongst  these  patients  twenty-eight 
acknowledged  having  had  syphilis,  while  six  denied  any 
venereal  infection.  The  percentage  of  syphilitic  tabes  in 
this  set  of  cases  would  be  therefore  82*4,  and  of  the  non- 
syphilitic  17*6.  I  think  it  right  to  add  that  amongst  the  six 
patients  who  denied  syphilis,  there  were  two  who  had,  in 
consequence  of  the  peculiar   circumstances  in  which  they 

'  I  have  purposely  abstained  from  utilising  my  hospital  experience  of 
tabes  for  the  elucidation  of  this  subject,  as  I  have  found  the  state- 
ments of  hospital  patients  with  regard  to  previous  infection  in  general 
to  be  unreliable. 


80  SCLEROSIS  OP  THE  SPINAL  CORD. 

were  placed,  the  strongest  possible  inducement  to  refer 
the  disease  to  accidents,  and  to  deny  any  venereal  infec- 
tion. One  of  them  had  a  suspicions  papular  eruption  on 
the  chest. 

The  entire  percentage  in  the  two  sets  of  cases  would 
therefore  amount  to  86*5  for  syphilitic  and  13*5  for  non- 
syphilitic  tabes. 

In  Germany  it  was  chiefly  Erb  ^  who  made  himself  the 
champion  of  the  syphilitic  theory  of  tabes.  He  found  that, 
out  of  122  cases  which  had  occurred  in  his  practice,  syphilis 
had  preceded  tabes  in  89  per  cent.  To  these  he  added 
more  recently  another  set  of  cases,  bringing  the  whole  up 
to  200.  In  the  latter  cases  the  percentage  amounted  to 
91 .  In  twelve  hundred  cases  of  other  nervous  affections 
the  percentage  for  antecedent  syphilis  was  only  22'75, 
while  77*25  had  presented  no  syphilitic  manifestations. 
Erb  was  therefore  led  to  the  conclusion  that  few  people 
who  have  not  had  syphilis  are  likely  to  get  tabes. 
Leyden,^  on  the  contrary,  states  in  a  somewhat  peremptory 
manner  that  the  theory  is  wrong,  because  it  is  based  on 
statistics  only,  and  that  statistics  may  prove  anything.  He 
considers  that  the  anatomical  changes  found  in  tabes  have 
not  the  slightest  resemblance  to  other  notorious  lesions  of 
syphilis,  and  that  specific  treatment  does  no  good  in  tabes. 
For  these  reasons  he  rejects  the  specific  theory  of  the 
disease  ;  yet  in  the  same  paper  he  states  that  iodide  of 
potassium  must,  after  all,  be  looked  upon  as  the  most  useful 
remedy  for  it  !  Westphal,  ^  whose  opinion  is  entitled  to  the 
highest  respect,  has  likewise  been,  from  the  beginning,  a 
consistent  opponent  of  this  theory.     He  has  no  faith  in 

1  '«  Centralblatt,  etc.,"  1881,  p.  195;  and  "Transactions  of  the  In- 
ternational Medical  Congress,"  1881,  vol.  ii.,  p.  32;  and  ''Berliner 
khnisclie  Wochenschrift,"  No.  32,  1883. 

2  "  Tabes  DorsaHs,"  in  Eulenburg's  "  Encyclopadie,  etc."  "Wien  und 
Leipzig,  1883. 

3  '<  Archiv  fiir  PsycMatrie."     Berlin,  1879-83. 


ETIOLOGY.  81 

statistics,  as  he  finds  it  impossible  to  rely  on  the  state- 
ments of  patients.  Some  of  these  latter  consider  any  sore 
on  the  sexual  organs  to  be  venereal,  and  even  surgeons  are 
in  the  habit  of  treating  any  abrasion  on  those  parts  as 
syphilitic  in  order  to  be  on  the  safe  side. 

Where  opinions  amongst  those  best  qualified  to  judge 
differ  so  widely,  a  full  discussion  of  all  the  different  points 
in  dispute  appears  to  me  the  only  way  to  arrive  at  the  facts 
of  the  matter. 

1.  With  regard  to  statistics,  it  seems  hardly  fair  to  ex- 
clude them  altogether,  as  they  are  constantly  utilised  for 
determining  various  points  in  the  pathology  of  other 
diseases,  such  as  fevers,  consumption,  epilepsy,  etc.  To 
my  mind  the  adversaries  of  the  syphilitic  theory  of  tabes 
would  combat  this  view  more  effectually  if  they  would 
furnish  us  with  statistical  data  from  their  own  practice, 
showing  that  syphilis  has  been  absent  in  a  large  proportion 
of  cases.  All  the  percentages  which  have  been  published 
are  in  favour  of  syphilis  being  of  great  influence  in 
leading  to  the  appearance  of  the  disease.  They  are  as 
follows  : — 


Althaus  ... 

86-5 

Gowers 

70 

Bernhardt 

58-8 

Pusinelli    . . . 

52 

Buzzard  ... 

45 

Quinquano 

100 

Erb 

90 

Ross 

95 

Fournier . . . 

91-4.5 

Yulpian 

75 

This  surely  cannot  be  a  simple  coincidence  ;  moreover,  if 
all  the  facts  were  known,  it  seems  probable  that  these  per- 
centages would  appear  even  higher  than  they  actually  are. 
It  is  well  known  that  syphilis  is  often  overlooked  by  care- 
less persons,  where  its  manifestations,  whether  primary  or 
secondary,  are  mild.  A  small  primary  sore,  which  heals 
readily  in  a  short  time,  may  be  followed  by  a  few  spots  of 
roseola  and  a  slight  soreness  in  the  throat  and  tongue. 
This  disappears  with  or  without  any  treatment,  and  the 

G 


82  SCLEROSIS  OF  THE  SPINAL  CORD. 

patient  thinks  that  he  never  had  syphilis  ;  yet  four,  five  or 
ten  years  afterwards  double  vision  and  a  severe  attack  of 
lightning  pains  may  herald  the  invasion  of  tabes,  which 
is  as  plainly  owing  to  the  venereal  disease  as  gummata  or 
sarcocele. 

2.  It  is  frequently  noticed  in  practice  that  patients  deny 
having  ever  exposed  themselves  to  infection,  at  a  time 
when  they  show  the  most  evident  signs  of  it.  More 
especially  in  hospital  we  often  see  patients  who  are  covered 
all  over  with  a  syphilitic  rash,  and  have  ulceration  in  the 
throat  and  palate,  and  yet  state  plainly  that  they  never  had 
any  "venereal."  Even  private  patients,  who  ought  to  know 
better,  occasionally  suppress  the  information  which  is  so 
important  for  us,  from  a  sense  of  false  shame.  Some  no 
doubt  forget  it  in  the  course  of  time  ;  others  overlook  it ; 
and  where  there  has  been  a  urethral  chancre  or  inherited 
syphilis,  patients  may  be  well  excused  for  not  knowing 
that  they  ever  had  such  a  complaint. 

Case  1. — In  August,  1879,  Dr.  Wright,  of  Derby,  asked 
me  to  see  a  commercial  traveller,  aged  fifty-three,  who  had 
been  twice  married,  and  acknowledged  having  exceeded 
a  good  deal  in  his  sexual  relations.  His  habits  had  been 
irregular.  Three  years  ago  his  present  illness  commenced 
with  a  feeling  of  numbness  in  both  hands.  When  he  put 
his  hands  into  his  pockets  to  feel  for  anything,  he  had  not 
the  least  notion  of  what  there  was  there.  I  made  him 
close  his  eyes,  and  put  coins  and  other  familiar  objects 
into  his  hands,  but  found  him  totally  unable  to  determine 
their  nature.  He  could,  however,  still  feel  sharp  prick- 
ing and  pinching.  He  had  optic  atrophy  in  both  eyes  to 
such  an  extent  as  to  be  unable  to  read  No.  19  of  Jaeger's 
text-types.  Argyll-Robertson's  symptom  was  present. 
The  hearing  on  the  left  ear  was  defective.  He  complained 
of  pain  in  his  legs,  which  was  sometimes  acute  and  dart- 
ing, at  other  times  dull,  and  was  frequently  confined  to  a 
small  area  in  the  leg  not  larger  than  a  crown-piece.     The 


ETIOLOGY.  83 

patellar  reflex  was  absent  in  both  sides.  He  was  very 
unsteady  on  his  legs  ;  could  not  stand  on  one,  without 
being  supported  and  with  his  eyes  open  ;  nor  could  he 
balance  himself  on  both  legs  with  his  eyes  closed.  The 
gait  was  ataxic  in  the  highest  degree  ;  he  had  the  greatest 
difficulty  in  going  downstairs,  and  in  the  dark  he  could  not 
walk  at  all.  The  spine  appeared  to  be  tender  on  pressure. 
The  bladder  was  sluggish  ;  the  sexual  power  and  desire 
very  much  diminished  ;  on  attempting  copulation,  erection 
was  imperfect,  and  ejaculation  premature.  He  had  lately 
been  often  subject  to  small  abscesses  on  the  second  finger  of 
the  left  hand,  which  made  the  whole  arm  so  tender  that  he 
was  unable  to  use  it.  On  being  asked  whether  he  had 
had  syphilis  at  one-time  or  another,  he  answered,  "that  he 
thought  he  had  had  something,  but  did  not  remember  what 
it  was ;  yet  he  believed  that  a  doctor  had  burned  him." 

In  the  following  case,  antecedent  syphilis  was  at  first 
denied,  and  subsequently  acknowledged  : — 

Case  2. — In  October,  1879,  Mr.  Bader  asked  me  to 
see  a  merchant,  aged  forty-four,  who  had  for  three 
years  past  suffered  from  paralysis  of  the  left  rectus  ex- 
ternus  muscle  and  gradually  advancing  atrophy  of  both 
optic  nerves.  He  could  only  just  read  No.  6  Jaeger  ;  had 
achromatopsia  and  bilateral  myosis.  He  denied  having 
ever  had  any  syphilis,  and  attributed  his  illness  to 
excessively  hard  work  and  annoyance  in  business.  He 
also  suffered  from  chorea,  which  had  commenced  during 
childhood  and  never  left  him  ;  and  he  had  been  impotent 
for  five  years.  The  patellar  reflex  was  absent,  and  there 
was  some  ataxy  in  standing,  but  not  in  walking.  After 
the  patient  had  been  under  my  care  for  some  time,  he 
one  day  told  me  that  he  had  really  had  syphilis  about  ten 
years  ago,  and  suffered  for  twelve  months  from  various 
manifestations  of  the  distemper,  chiefly  in  the  mouth  and 
throat.  He  gave  as  his  reason  for  denying  this,  in  the  first 
instance,  that  "  the  very  thought  of  his  foolish  behaviour  at 

g2 


'84  SCLEROSIS  OF  THE  SPINAL  CORD. 

that  time  annoyed  liim  so  much  that  he  preferred  not  to 
talk  about  it." 

Case  3. — In  April,  1879,  I  was  consulted  by  a  merchant, 
^ged  thirty-five,  married,  and  father  of  four  children,  who 
attributed  the  symptoms  of  tabes  from  which  he  was  then 
suffering  to  an  accident  which  he  had  had  in  a  tram-car. 
Ten  months  ago  he  noticed  that  he  suddenly  saw  everything 
double  ;  and  the  right  eye  was  turned  inwards,  so  that  he 
evidently  had  had  paralysis  of  the  right  rectus  externus. 
He  recovered  from  this  in  about  three  months.  When  I 
first  saw  him  there  was  a  degree  of  ptosis  in  the  right  eyelid, 
making  the  right  eye  look  considerably  smaller  than  the  left. 
The  knee-jerk  was  absent  in  both  sides.  Walking  was 
troublesome,  the  right  leg  being  worse  than  the  left.  He 
could  stand  pretty  well  on  the  left  leg,  but  could  not 
balance  himself  when  standing  on  the  right.  There  was 
a  tight  feeling  across  the  chest  and  throat,  and  great  numb- 
ness from  the  waist  downwards.  I  asked  him  whether  he 
had  had  syphilis,  and  he  denied  it  indignantly.  On  ex- 
amining the  penis,  however,  I  discovered  an  enormous  scar 
on  the  gland.  To  my  question  as  to  the  origin  of  this  scar, 
the  patient  replied  that  it  was  owing  to  the  resistance  he 
had  experienced  on  consummating  marriage  !  It  had,  how- 
■ever,  all  the  appearance  of  a  syphilitic  cicatrix  ;  and  the 
patient  eventually  recovered  completely  under  specific  treat- 
ment. 

In  some  cases  the  initial  symptoms  of  syphilis  are  so 
very  slight  that  a  lay  patient  might  have  some  difiiculty  in 
believing  that  so  little  could  have  led  to  so  much  ;  while 
the  medical  intellect  is  better  able  to  grasp  the  full  bearings 
of  this  influence. 

Case  4. — In  September,  1 882, 1  was  consulted  by  an  Irish 
practitioner,  aged  forty,  single,  who  told  me  at  the  begin- 
ning of  the  interview  that  twenty  years  ago  he  had  had  a  very 
mild  form  of  syphilis,  namely,  a  small  chancre  which  healed 
rapidly,  and  six  weeks  afterwards  a  slight  ulceration  in  the 


ETIOLOGY.  85 

tongue.  He  bad  never  Lad  any  rash  on  the  skin,  or  ulcera- 
tion in  the  throat,  or  any  further  manifestation  of  the 
specific  diathesis  ;  and  he  had  remained  apparently  in  very 
good  health,  for ^f teen  years.  Five  years  ago,  however,  the 
first  symptoms  of  his  present  illness  appeared,  and  affected 
more  particularly  the  right  side  of  the  body.  Dimness 
in  the  vision  of  the  right  eye  came  first,  and  optic  atrophy 
is  now  well  established.  Lightning  pains  in  the  right  knee 
then  supervened,  and  are  at  present  apt  to  come  on  in 
almost  any  part  of  the  body.  They  last  a  few  hours,  and 
then  vanish,  generally  under  the  influence  of  chloral. 
Eight  or  ten  days  afterwards  there  is  another  bout  of  pain. 
There  is  a  slight  degree  of  ptosis  of  the  right  eyelid,  but 
no  palsy  in  the  muscles  which  move  the  eye  itself.  Great 
numbness  is  felt  in  the  sphere  of  the  right  ulnar  nerve.  The 
sexual  power  and  desire  are  gone.  Twelve  months  ago  he 
had  the  last  imperfect  connection,  but  he  still  has  occa- 
sionally seminal  emissions  during  sleep.  The  bladder  is 
sluggish  ;  incontinence  is  not  unfrequent  ;  the  bowels  are 
constipated.  The  knee-jerk  is  absent  in  both  sides,  and  the 
muscles  of  the  lower  extremities  are  much  wasted.  The 
patient  staggers  when  standing  with  his  eyes  closed  and  in 
the  dark  ;  and  the  gait  shows  well-marked  ataxy.  He  had 
never  been  able  to  take  iodide  of  potassium  ;  and  had  just 
returned  from  Aix  la  Chapelle,  where  he  had  had  forty  mer- 
curial inunctions  without  the  least  result. 

It  may  be  safely  assumed  that,  if  this  patient  had  not  been 
a  medical  man,  he  might  have  forgotten  all  about  the  very 
slight  specific  affection  which  had  preceded  the  outbreak  of 
tabes  by  fifteen  years.  As  it  was,  however,  he  was  quite 
convinced  of  the  syphilitic  nature  of  his  affection,  as  he 
could  not  think  of  any  other  cause  which  might  have  led  to 
his  present  ilhiess. 

Case  5. — In  August,  1881,  Dr.  Meurer,  of  Wiesbaden, 
sent  a  gentleman  to  me  who  was  forty-two  years  old, 
married,  and  a  great  sportsman.   Some  years  ago  he  noticed 


86  SCLEROSIS  OF  THE  SPINAL  CORD. 

that  lie  saw  everything  double,  and  had,  therefore,  great 
difficulty  in  shooting.  This  arose  apparently  from  paresis 
of  the  right  rectus  internus.  When  I  saw  him,  that  muscle 
was  quite  paralysed,  and  there  was  also  ptosis  and  paralysis 
of  the  rectus  superior  of  the  right  eye.  The  tendon  re- 
flexes in  the  knee  were  absent,  and  the  patient  experienced 
the  characteristic  difficulties  in  walking  and  standing. 
On  my  asking  him  whether  he  had  had  syphilis,  he  said 
that  twenty-five  years  ago  he  had  had  a  "  soft  sore  which 
lasted  only  two  days  "  ;  that  he  had  swallowed  large  doses 
of  iodide  of  potassium,  and  had  undergone  a  long  treatment 
at  Aix-la-Chapelle  without  the  slightest  benefit ;  and 
that  he  did  not  consider  that  he  really  ever  had  had 
syphilis. 

Fournier's  experience  with  regard  to  this  particular  is 
that  tabes  generally  becomes  developed  where  the  early 
symptoms  of  syphilis  have  been  unusually  mild.  Amongst 
eighty-four  cases  in  which  this  point  was  particularly 
inquired  into,  there  was  not  one  of  severe  syphilis  ;  ten  were 
of  medium  intensity,  twenty-one  mild,  forty  very  mild;  in  ten 
there  had  been  a  chancre  without  subsequent  secondary 
symptoms  ;  and  in  three  the  patients  were  unaware  that  they 
had  had  syphilis.  He  says  that  most  of  his  tabid  patients 
have  only  had  a  slight  rash  on  the  skin,  insignificant  erosions 
of  mucous  membranes,  alopecia,  and  swollen  lymphatic 
glands  ;  and  that  all  these  symptoms  disappeared  rapidly 
with  or  without  treatment.  A  natural  consequence  of  this 
is  that  such  cases  are  insufficiently  treated.  Of  seventy- 
nine  such  patients,  two  had  undergone  no  treatment  at  all, 
forty-six  had  had  treatment  extending  from  a  fortnight  to 
four  months,  while  thirty-one  had  had  a  longer  treatment. 
It  is,  however,  well  known  that  syphilis  cannot  be  cured 
by  a  short  treatment,  which  latter  does  little  but  suppress 
its  manifestations  for  the  time  being. 

In  other  cases,  however,  the  syphilitic  symptoms  are  pro- 
longed and  severe,  and  become  so  intertwined  with  those  of 


ETIOLOGY.  87 

tabes,  that  no  one  would  be  able  by  any  amount  of 
sophistry  to  explain  away  the  connection  between  the  two 
diseases. 

Case  6. — In  January,  1883,  I  saw  a  patient  in  consulta- 
tion with  Dr.  Mullar,  of  Kilburn,  who  was  aged  thirty-one,  a 
baker  by  trade,  married  and  childless,  and  who  had  had  a  hard 
chancre  and  a  bubo,  quickly  followed  by  secondaries,  six 
years  ago.  Ever  since  that  time  he  had  suffered  from  some 
constitutional  manifestations  of  the  syphilitic  dyscrasia, 
being  never  thoroughly  well.  Six  months  ago,  sarcocele 
became  developed  in  the  left  testicle.  Ten  days  ago  he 
had  a  severe  epileptic  fit,  which  lasted  five  minutes  ;  and 
the  day  before  I  saw  him  he  had  had  another,  in  which  he 
passed  the  excretions  under  him.  His  memory  had  of  late 
become  much  impaired  ;  he  was  unable  to  attend  to  his  busi- 
ness, in  consequence  of  feeling  always  muddled  and  confused. 
The  knee-jerk  was  absent  on  both  sides,  and  the  patient  stag- 
gered when  standing  with  his  eyes  closed.  I  saw  him 
again  in  the  following  October,  when  some  additional 
symptoms  of  tabes,  viz.,  paralysis  of  the  left  rectus 
externus  and  lightning  pains,  had  made  their  appearance. 
The  mental  hebetude  was  more  marked,  and  alternated  with 
violent  outbreaks  of  temper.  On  one  occasion  he  made  an 
indecent  proposal  to  his  nurse,  in  the  presence  of  several 
other  people  ;  then  threw  himself  on  the  floor,  where  he 
rolled  about  on  all  fours,  and  swore  in  such  a  frightful  way 
that  he  terrified  all  those  present.  The  symptoms  of  tabes 
were  in  this  case  evidently  being  developed  together  with 
those  of  general  paralysis  of  the  insane  ;  and  meningo- 
encephalitis, combined  with  sclerosis  of  the  posterior 
columns,  would  most  probably  be  found,  were  it  to  come 
to  an  inspection. 

Case  7. — About  the  same  time  I  saw,  in  consultation  with 
Dr.  Grasemann,  a  patient  who  was  an  auctioneer,  aged 
forty-four,  married,  but  childless,  and  who  had  had  a  some- 
what severe  form  of  syphilis  ten  years  ago.     There  had 


88  SCLEROSIS  OF  THE  SPINAL  CORD. 

been  an  indurated  chancre  and  a  bubo,  followed  by  bad  and 
prolonged  secondary  symptoms.  He  had  altogether  lived 
a  wild  life,  masturbated  as  a  boy,  committed  venereal 
excesses  later  on,  and  had  drunk  and  smoked  heavily.  He 
had  suffered  from  diplopia  some  time  ago  ;  and  five  years 
ago  had  an  attack  of  aphasia  and  right  hemiplegia,  from 
which  he  recovered  in  a  few  days.  Several  such  attacks  had 
taken  place  since  then  at  intervals,  leaving  no  traces  after 
a  short  time.  The  last  hemiplegic  attack  occurred  only 
five  days  ago,  and  then  affected  the  left  side  of  the  body.  The 
memory  was  much  impaired,  and  the  patient  felt  occasionally 
so  confused  that  he  was  unable  to  attend  to  his  business^ 
When  I  saw  him,  the  hemiplegia  of  the  left  side  had 
already  disappeared.  There  was,  however,  total  loss  of 
knee-jerk,  Romberg's  symptom,  constipation  of  the  bowels, 
sexual  excitement  and  debility,  and  occasional  attacks  of 
spasmodic  incontinence  of  urine,  thus  rendering  the  diag- 
nosis of  tabes  certain. 

Occasionally  tabes  results  from  direct  inoculation  of  the 
syphilitic  virus. 

Case  8. — A  well-known  and  able  surgeon  consulted  me 
in  May,  1871,  and  informed  me  that,  while  examining  a 
woman  in  a  workhouse  infirmary  in  1866,  he  inoculated  the 
index  of  the  right  hand  with  syphilis.  For  two  years 
afterwards  he  was,  to  use  his  own  words,  never  free  from 
that  wretched  disease  in  one  form  or  another.  He  then 
became  apparently  quite  well,  and  continued  so  until 
Christmas,  1870,  when  he  was  rather  suddenly  seized  with 
tingling  in  the  legs  and  numbness  in  the  left  arm  and  side 
of  the  body ;  a  day  or  two  afterwards  double  vision 
supervened,  and  there  was  a  feeling  of  constriction  round 
the  waist  and  inability  to  walk.  Some  of  the  medical 
friends  whom  he  consulted  thought  the  symptoms  owing  to 
the  extreme  cold  which  prevailed  at  that  time,  while  others 
believed  them  due  to  syphilis  ;  and  there  was,  therefore, 
some  hesitation  how  to  treat  it.     However,  he  slowly  but 


ETIOLOGY.  89 

steadily  improved,  and  was  able  during  the  last  six  months 
to  resume  his  practice.  He  now  complained  chiefly  of  more 
or  le^s  constant  constriction  round  the  waist,  which  was  at 
times  almost  unbearable.  His  left  arm  and  both  legs  were 
numb  and  stiff.  He  could  not  balance  himself  with  his 
eyes  shut,  but  would  fall  backwards  unless  supported.  He 
also  had  sudden  shocks  of  stabbing  pain  in  the  lower 
extremities,  and  on  awaking  in  the  morning  felt  a  curious 
wave  of  sensation  flowing  down  the  left  arm  and  up  the 
legs  towards  the  perineeum. 

3.  Several  observers  have  expressed  the  opinion  that  the 
morbid  anatomy  of  tabes  speaks  against  the  syphilitic 
origin  of  the  disease.  Thus  Chauvet  ^  says  "  that  syphilis 
can  never  cause  a  primary  sclerosis  of  the  posterior  root- 
zones."  Lancereaux  ^  considers  that  the  lesions  of  tertiary 
syphilis  never  invade  an  organ  through  its  whole  extent  ; 
they  are,  according  to  him,  circumscribed,  forming  single  or 
multiple  nodes  grouped  in  one  or  several  spots,  which 
undergo  a  granular,  fatty,  or  hyaline  degeneration,  and  ter- 
minate in  loss  of  substance  or  a  cicatrix.  The  lesions  of 
tabes,  on  the  other  hand,  are  diffuse,  extended,  systematic, 
and  although  slowly  developed,  like  those  of  syphilis,  do 
not  produce  loss  of  substance,  nor  do  they  leave  a  scar. 
Westphal  expresses  a  similar  opinion  ;  yet  I  do  not  hesitate 
to  say  that  no  one,  however  experienced,  is  able  by  inspec- 
tion alone,  even  if  aided  by  the  microscope,  finally  to  decide 
what  is  syphilitic  or  not.  Moreover,  we  are  familiar 
with  diffuse  changes  occurring  not  only  in  the  blood-vessels, 
but  also  in  the  liver,  kidneys,  and  other  organs,  and  which 
are  generally  acknowledged  to  be  owing  to  syphilis. 
Diffuse  acute  hepatitis  and  acute  glossitis  may  be  of  a 
specific  nature,  and  affect  the  whole,  or  almost  the  whole,  of 
the  liver  or  tongue.   Lancereaux's  statement,  that  tabes  does 

'  «  Th^ee  de  Paris,"  No.  55.     Paris,  1880. 

2  "Transactions  of  the  International  Congress,  London,  1881." 
vol.  ii.,  p.  40. 


90  SCLEROSIS  OF  THE  SPINAL  CORD. 

not  produce  any  loss  of  substance,  seems  to  be  somewhat 
of  a  solecism  ;  for  what  is  wasting  but  loss  of  substance  ? 

On  looking  through  pathological  literature  we  find  all 
and  every  kind  of  lesion  in  the  spinal  cord  described  by  re- 
liable observers  as  arising  from  syphilis.  Cases  are  on 
record  of  acute  myelitis,  either  diffuse  or  limited  to  certain 
portions  of  the  cord,  such  as  the  lumbar  enlargement,  the 
lumbo-dorsal,  dorsal,  and  cervical  portion  ;  this  again  may 
be  transverse,  superficial,  or  central.  Then  we  find  cases  of 
acute  ascending  spinal  paralysis  without  any  appreciable 
anatomical  lesion,  and  of  all  the  different  forms  of  chronic 
myelitis  ;  while  all  the  different  systems  of  the  cord,  in- 
cluding the  anterior  horns,  have  been  seen  to  be  separately 
or  collectively  affected.  If  this  be  true — and  any  one  may 
convince  himself  that  it  is  by  searching  the  vast  storehouses 
of  the  records  of  morbid  anatomy — then  we  can  certainly 
not  accept  the  statement  ex  cathedra^  that  syphilis  cannot 
produce  sclerosis  of  the  posterior  columns.  The  principal 
lesions  of  tertiary  syphilis  are  gummata  and  sclerosis.  The 
hard  chancre,  to  begin  with,  is  a  form  of  sclerosis  ;  and  the 
*'  cirrhosis  "  which  is  found  in  the  tertiary  period  in  the 
rectum,  the  liver,  lungs,  and  kidneys  is  nothing  but 
sclerosis. 

The  objection  that  syphilis  never  produces  any  system- 
disease  elsewhere  is  surely  untenable.  We  know  that  the 
distemper  often  attacks  exclusively  such  systems  as  the  skin 
and  hair,  the  lymphatic  glands,  and  the  periosteum.  As  the 
syphilitic  virus  is  one  of  a  highly  specialised  character,  it 
seems  only  rational  to  expect  that  it  should  affect  certain 
systems  in  preference  to  others.  Nobody  doubts  that  the 
influence  of  cold  may  produce  tabes  ;  but  it  is  certainly 
more  difficult  to  understand  how  a  general  cause,  like  cold, 
should  set  up  morbid  changes  in  special  systems  than 
that  a  special  poison  like  syphilis  should  do  so. 

Quite  apart  from  this,  however,  we  have  seen  (p.  48)  that 
tabes  is  not  absolutely  a  system-disease  confined  to  the  pos- 


ETIOLOGY.  91 

terior  columns  of  the  cord,  but  that  almost  invariably,  besides 
sclerosis  of  those  parts,  posterior  spinal  meningitis,  wasting 
of  the  posterior  roots  and  the  posterior  cornua  of  the  grey 
matter,  and  of  Clarke's  vesicular  columns,  is  found,  while 
the  ganglionic  cells  of  the  anterior  grey  matter  are  not  unfre- 
quently  seen  to  be  wasted,  and  the  cranial  nerves  sclerosed. 
We  are  therefore  justified  in  stating  that  tabes  is  a  much 
more  general  disease  than  is  expressed  by  the  term  "sclerosis 
of  the  posterior  columns." 

The  idea  that  something  absolutely  special  ought  to  be 
discovered,  showing  a  definite  syphilitic  origin,  appears 
unreasonable,  more  especially  if  we  consider  that  what  is 
called  the  "  classical  type  "  of  tabes  is  probably  only  rarely 
idiopathic,  and  much  more  frequently  specific. 

Finally,  it  will  surely  be  acknowledged  that  where 
morbid  anatomy  and  clinical  medicine  appear  to  clash  con- 
cerning the  nature  of  a  disease,  the  latter  science  should 
carry  the  day.  I  may  here  fittingly  refer  to  an  interesting 
discussion  which  took  place  at  a  recent  meeting  of  the 
Clinical  Society  of  London^  (October  26th,  1883),  when 
I  brought  forward  a  case  of  apparently  syphilitic  tumours 
of  the  cerebral  membranes,  in  a  patient  in  whom  there  had 
been  no  history  of  congenital  or  acquired  syphilis  during 
life.  The  anatomical  appearances  in  that  case  were  as  cha- 
racteristic as  possible  for  syphilis  ;  yet  there  was  an  almost 
unanimous  expression  of  opinion  on  that  occasion  that 
anatomical  structure  without  life-history  is,  in  a  general  ivay, 
insufficient  for  a  diagnosis,  and  that  the  tumours  which  were 
described  might  have  been  owing  to  the  tubercular  or  some 
other  dyscrasia. 

4.  Another  objection  which  is  frequently  made  to  the  syphi- 
litic theory  of  tabes  is,  that  we  do  not  find  any  special  symptoms 
in  syphilitic  tabes  which  would  distinguish  it  at  a  glance 
from  ordinary  tabes.  I  have  already  mentioned  that  it  was 
this  circumstance  which  deterred  Duchenne  from  pronouncing 
>  "  British  Medical  Journal,"  vol.  ii.,  1883,  p.  874. 


92  SCLEROSIS  OF  THE  SPINAL  COKD. 

himself  more  strongly  for  the  syphilitic  "origin  of  the 
disease.  If  we  consider,  however,  that  the  description  of 
the  symptoms  of  tabes  is  in  general  taken  from  cases  of 
syphilitic  tabes,  we  can  no  longer  be  surprised  at  that  cir- 
cumstance. Moreover  it  is  obvious  that  such  an  objection, 
if  allowed,  must  also  apply  to  other  forms  of  tertiary 
disease,  more  especially  to  that  which  is  apt  to  occur  in  the 
brain,  and  which  is  by  general  consent  taken  to  be 
syphilitic.  An  attack  of  hemiplegia  from  disease  of  the 
cerebral  blood-vessels  may  have,  and  often  has,  exactly  the 
same  symptoms  as  one  arising  from  embolism  or  cerebral 
haemorrhage,  where  there  is  not  an  atom  of  syphilis  in  the 
case.  Some  of  the  visceral  complaints  induced  by  syphilis 
do  not  produce  symptoms  which  are  very  different  from 
those  owing  to  idiopathic  disease  of  the  same  viscera* 
The  symptoms  of  tabes  should  be  looked  upon  as  the 
response  of  the  posterior  columns  of  the  cord  to  certain 
injurious  influences  ;  and  this  view  explains  why  all 
symptoms  which  occur  in  non-syphilitic  tabes  may  occur  in 
the  specific  form  of  the  disease,  and  vice  versa.  The  chief 
difference  we  find  in  the  syphilitic  form  is,  that  there  are 
not  unfrequently  other  symptoms  of  venereal  affection  not 
referable  to  the  cord. 

5.  This  leads  us  to  speak  of  another  objection  which  has 
been  made  to  the  theory  which  we  are  now  considering,, 
viz.,  that  in  tabes  we  do  not  meet  with  any  other  of  the 
well-hnown  symptoms  of  syphilis.  To  this  I  would  reply, 
that  if  such  symptoms  are  properly  looked  for,  they  are 
frequently  discovered  ;  they  were  very  striking  in  one  of 
the  cases  which  I  have  just  related  (No.  6),  and  to  which 
I  could  add  many  others.  Indeed,  it  is  not  at  all  uncommon 
to  find  primary  or  secondary  cicatrices  in  the  skin,  loss  of 
substance  in  the  uvula,  sarcocele,  exostoses,  and  other 
notorious  symptoms  of  syphilis  in  such  patients  ;  while 
evidence  of  brain-syphilis,  more  particularly  of  the  con- 
gestive form  of  it,  is  likewise  frequent.     At  the  same  time 


ETIOLOGY.  93 

no  doubt  cases  occnr  where  such  symptoms  are  absent,  more 
especially  in  the  skin  and  mucous  membranes  ;  but  at  this 
we  cannot  be  surprised,  if  we  consider  that  tabes  is  in 
general  a  tertiary  manifestation  of  the  syphilitic  distemper. 
Similarly  we  find  that  in  specific  brain-disease  hemiplegia, 
with  late  rigidity  of  the  paralysed  muscles,  may  be  the  only 
symptom  ;  while  the  clinical  history  of  the  case  shows 
quite  plainly  that  the  nature  of  the  afiection  is  syphilitic. 
A  very  marked  case  of  this  sort,  which  occurred  some 
time  ago  in  my  practice,  is  described  in  the  "  Transactions  of 
the  Clinical  Society  of  London."^  General  paralysis  of  the 
insane  frequently  ends  the  career  of  the  tabid  as  well  as  of 
some  syphilitic  patients. 

6.  A  final  objection  which  is  frequently  made  to  the 
syphilitic  theory  of  tabes  is,  that  the  malady  is  not  cured 
by  specific  treatment.  A  cure,  however,  of  any  affection 
which  has  already  destroyed  highly  specialised  structures  is 
impossible  under  any  circumstances.  It  is  quite  true  that 
syphilitic  patients  daily  recover  their  health  under  specific 
treatment ;  yet  no  amount  of  mercury  and  iodide  of  potassium 
iv^ill  restore  a  large  hole  that  has  been  made  in  the  palate,  or 
the  peculiar  structure  of  a  testicle  which  has  undergone  the 
process  of  sarcocele.  Now  it  is  well  known  that,  even  in 
the  beginning,  tabes  is  not  a  functional,  but  a  structural 
disease  (p.  42)  ;  and,  in  general,  all  we  can  expect  there- 
fore is  to  arrest  the  further  progress  of  the  complaint,  and 
to  cure  or  improve  those  symptoms  which  do  not  depend 
upon  absolute  destruction  of  nervous  matter.  Specific  treat- 
ment is  mostly  useless  when  the  second  stage  of  the 
disease  has  been  well  established  ;  and  likewise  for  the 
amblyopia  and  amaurosis  of  the  first  stage.  The  more 
highly  specialised  the  structures  affected,  the  less  likely  is 
treatment  to  act  beneficially ;  and  this  is  no  doubt  the  reason 
why  optic  atrophy  constitutes  such  a  hopeless  subject  for 
therapeutics. 

»  Vol.  XV.,  p.  203.     London,  1882. 


94  SCLEROSIS  OF  THE  SPINAL  CORD. 

Syphilitic  brain-disease  is  equally  rebellious  to  specific 
treatment  when  it  has  once  proceeded  to  destruction  of  spe- 
cialised structures.  No  amount  of  iodide  of  potassium 
will  ever  cure  softening  of  the  motor  zone  of  the  brain,  from 
thrombosis  of  the  middle  cerebral  artery  ;  yet  the  clearest 
possible  connection  may  exist  between  the  primary  venereal 
disease  and  the  subsequent  affection  of  the  cerebral  blood- 
vessels. 

Most  cases  of  tabes  which  come  under  our  care  in  practice 
have  already  lasted  a  number  of  years  before  they  are  recog- 
nised. Only  too  frequently  lightning  pains  are  put  down  to 
I'heumatism  or  gout,  and  palsies  of  ocular  muscles  to  exposure 
to  wind.  Yet  many  years  ago  Ricord  said  that  the  para- 
lysis of  an  ocular  muscle  was  the  signature  of  syphilis  on 
the  eye  of  a  patient !  Fortunately  we  have  now  in  the 
loss  of  the  knee-jerk  a  diagnostic  test  of  the  utmost 
value  for  the  recognition  of  the  earliest  beginnings  of  tabes, 
and  one  which  will  no  doubt  lead  in  course  of  time  to  an 
immense  improvement  in  the  therapeutics  of  this  disease. 

While,  therefore,  confirmed  cases  of  syphilitic  tabes, 
where  the  disease  has  to  a  great  extent  run  its  course,  can- 
not be  cured  by  specific  treatment,  the  latter  is  very  useful 
as  long  as  an  irritant  morbid  process  is  still  actively  going 
on  in  the  cord.  The  newer  a  symptom,  the  more  likely  it  is  to 
yield  to  mercury  or  iodide  of  potassium  ;  yet  even  old 
symptoms,  if  occurring  in  less  highly  specialised  structures, 
are  often  greatly  benefited.  This  is  more  particularly  the 
case  with  the  lightning  pains,  which  may  yield  to  the 
hydrargic  perchloride  after  having  resisted  subcutaneous  in- 
jections of  morphia.  The  further  progress  of  the  disease 
may  also  be  often  arrested  ;  and  patients,  who  were  fast 
going  down  hill,  often  regain  at  least  some  degree  of  health 
and  comfort  by  a  specific  treatment.  The  patient  whose 
case  is  referred  to  on  p.  84  recovered  completely.  Rumpf, 
of  Bonn,  has  cured  a  man  who  was  in  the  second  stage  of 
tabes,  by  mercurial  treatment   continued  for  eight  months 


ETIOLOGY.  95 

consecutively.  Hammond  reports  a  similar  case.  Palsies 
of  ocular  muscles  are  now  often  in  the  very  begin- 
ning treated  energetically  on  a  specific  plan,  with  the 
result  that  the  patients  not  only  recover  from  such  palsies, 
but  never  develop  other  symptoms  which  may  have  been 
on  the  point  of  breaking  out.  Even  Leyden,  who  utterly 
scouts  the  idea  of  any  connection  between  tabes  and 
syphilis,  is  compelled  to  acknowledge  that  after  all  iodide 
of  potassium  is  the  best  medicine  for  this  disease  !  {loc. 
cit.,  p.  46). 

The  time  during  which  the  syphilitic  germs  breed  in  the 
system  before  they  can  produce  tabes  varies  in  different 
individuals.  The  most  frequent  period  of  its  outbreak  is 
between  six  and  ten  years  after  the  primary  infection.  In 
exceptional  cases  it  is  much  earlier,  and  I  have  now  a 
patient  under  my  care  in  the  hospital,  in  whom  it  appeared 
a  twelvemonth  after  a  chancre  : — 

Case  9. — In  April,  1883,  Dr.  Shepard,  of  the  Euston-road, 
asked  me  to  see  an  artist,  aged  forty,  single,  who  had  con- 
tracted syphilis  from  amodel  eight  years  ago.  Twelve  months 
afterwards  undoubted  symptoms  of  tabes  appeared,  as  the 
patient  found  great  difficulty  in  standing  and  walking,  and 
showed  the  characteristic  gait  of  ataxy.  He  likewise 
suffered  from  attacks  of  lightning  pains,  which  were,  how- 
ever, not  of  a  severe  character,  and  appeared  at  long  in- 
tervals. He  was  treated  by  iodide  of  potassium,  which  did 
no  good  at  all  ;  after  that  he  was  subjected  to  inunction  with 
mercurial  ointment,  and  given  blue  pill,  which  did  good  for 
a  time,  but  then  seemed  to  lose  its  effect,  as  the  disease 
gradually  gained  upon  him.  When  I  saw  him,  he  was  just 
able  to  walk  a  few  steps  on  level  ground  with  the  aid  of 
two  sticks  ;  showed  the  classical  gait  of  ataxy,  and  had 
lost  his  patellar  reflexes.  He  could  hardly  stand  with  his 
feet  wide  apart  and  his  eyes  open,  and  would  have  gone 
down  at  once  if  the  feet  had  been  approached  to  one 
another  and  the  eyes  closed.     Yet  he  had  no  difficulty  in 


96  SCLEROSIS  OF  THE  SPINAL  CORD. 

crossing  one  leg  over  another,  and  showed  considerable 
muscular  force  in  resisting  attempted  flexion  of  the  knees. 
The  brain  and  cranial  nerves  were  healthy.  He  suffered 
from  obstinate  constipation,  and  the  sexual  power  was  com- 
pletely lost.  There  was  numbness  in  the  soles  of  the 
feet,  but  in  all  other  parts  of  the  body  sensibility  was  per- 
fectly normal.  As  neither  his  eyes  nor  his  hands  suffered 
in  any  way,  he  was  able  to  paint  almost  as  well  as  before 
the  beginning  of  his  illness,  the  only  thing  which  he  could 
not  do  being  to  take  a  perspective  of  his  pictures  by  walk- 
ing backwards  from  his  easel. 

Case  10. — Another  case  in  which  the  symptoms  of  tabes 
appeared  early  after  syphilis  was  that  of  a  merchant  whom 
Mr.  Bader  sent  to  me  in  February,  1880.  This  patient  was 
thirty-four  years  old,  married,  with  three  children,  and  had 
syphilis  and  gonorrhoea  ten  years  ago.  Twelve  months  after- 
wards lightning  pains  had  appeared,  which  affected  more 
or  less  all  parts  of  the  body.  Eighteen  months  ago  his 
sight  began  to  fail  :  he  has  now  Argyll-Robertson's  symp- 
tom and  amblyopia  from  atrophy  of  the  optic  nerve.  The 
patellar  reflex  is  absent.  The  legs  feel  as  if  they  did  not 
belong  to  him.  The  sexual  power  is  diminished  ;  yet  his 
wife  is  in  the  family  way,  and  he  had  had  connection  a 
fortnight  ago. 

On  the  other  hand,  the  patient  may  remain  for  many 
years  in  apparently  good  health  after  he  has  contracted 
syphilis  ;  so  that  the  appearance  of  the  first  symptoms  of 
tabes  is  believed  to  be  unconnected  with  the  specific  taint, 
and  put  down  to  other  causes. 

Case  1 1 . — Such  was  the  case  of  a  gentleman,  aged  forty- 
one,  single,  whom  I  saw  at  the  request  of  Mr.  Bader,  in 
August,  1883.  He  had  masturbated  heavily  at  school,  and 
contracted  syphilis  ten  years  ago.  The  symptoms  of 
this  illness  were  slight  and  of  short  duration,  and  the 
patient  had  been  in  thoroughly  good  health  until  about 
three  years  ago,  when  his  sight  commenced  to  become  dim. 


ETIOLOGY.  97 

This  was  at  first  believed  to  be  a  local  affection,  and  treated 
as  such  until  Mr.  Bader  suspected  it  to  be  part  and  parcel 
of  a  general  disease.  I  found,  on  examination,  loss  of 
knee-jerk,  Romberg's  symptom,  constipation,  difficulty  of 
micturition,  and  a  history  of  lightning  pains,  rendering  the 
diagnosis  of  tabes  certain. 

In  the  following  case,  the  interval  between  the  occurrence 
of  the  primary  sore  and  the  appearance  of  the  first  symptoms 
of  tabes  was  seventeen  years. 

Case  12. — In  May,  1883,  I  was  consulted  by  an  army 
surgeon,  aged  forty-two,  married,  with  three  children,  who 
had  had  syphilis  badly  twenUj  years  ago,  but  had  been 
apparently  quite  well  afterwards.  Three  years  ago  light- 
ning pains  appeared  in  the  legs,  arms,  and  head  ;  and  soon 
afterwards  considerable  difficulty  and  awkwardness  in 
walking  was  experienced.  At  present  he  can  walk  for 
about  fifteen  minutes  at  a  time,  after  which  he  is  thoroughly 
done  up.  There  is  numbness  in  the  legs  and  in  the  sphere 
of  both  ulnar  nerves.  Romberg's  symptom  is  well  marked. 
"  Belt-sensation "  is  troublesome  ;  and  the  knee-jerk  is 
absent  in  both  legs,  which  are  much  emaciated.  The  patient 
has  considerable  difficulty  with  his  bowels,  but  none  with  the 
bladder.  The  sexual  power  is  diminished,  yet  there  are 
not  unfrequently  nocturnal  emissions  of  semen. 

The  length  of  time  which  intervenes  between  the  out- 
break of  the  two  diseases  does  not  speak  against  their  standing 
in  the  relation  of  cause  and  effect.  In  other  diseases  many 
years  are  known  to  elapse  before  a  cause  produces  an  effect. 
Sir  Benjamin  Brodie  met  with  an  accident  while  riding  on 
horseback  in  1834,  dislocating  his  right  shoulder,  and  he 
eventually  died  of  cancer  which  had  become  developed  in 
the  same  joint  in  September,  1862,  which  gives  an  interval 
of  twenty-eight  years  between  the  injury  and  the  consecu- 
tive disease.  It  would  not  be  difficult  to  multiply  such 
examples.  Moreover,  no  one  thinks  of  denying  that  mani- 
festly syphilitic  symptoms  may  and  do  occur  in  the  bones, 

II 


98  SCLEROSIS  OF  THE  SPINAL  CORD. 

testicles,  and  even  in  the  skin,  as  long  as  twenty  or  thirty 
years  after  the  primary  affection. 

Some  of  those  observers  who  are  fond  of  attempting  to 
reconcile  contradictory  opinions  have  started  the  idea  that 
syphilis  acts  indirectly  in  producing  tabes,  and  is  what  is 
called  a  predisposing  cause.  It  is  said  to  lower  the  system, 
to  deprive  it  of  its  power  of  resistance,  and  in  this  way  to 
act  like  other  debilitating  influences,  such  as  masturbation, 
sexual  and  other  excesses,  etc.  This  view,  however,  is 
hardly  supported  by  what  we  see  in  practice.  In  many 
cases,  indeed,  so  far  from  being  debilitated  by  the  germs 
which  are  breeding  in  them,  the  patients  appear  to  be  quite 
well  and  strong  at  the  time  of  the  outbreak  of  tabes,  and 
this  more  especially  where  the  primary  and  secondary 
symptoms  have  been  slight: 

Case  13. — A  merchant,  aged  fifty-one,  married  and  father 
of  six  children,  consulted  me  in  February,  1881.  He  had 
had  syphilis  twenty  years  ago,  and  his  eldest  child  had 
been  syphilitic.  For  many  years  past  he  had  been  per- 
fectly well ;  but  in  March,  1880,  he  suddenly  saw  every- 
thing double.  He  consulted  the  late  Mr.  Critchett,  under 
whose  care  the  affection  disappeared  within  a  month.  He 
had  a  second  attack  of  the  same  thing  in  January,  1881, 
and  was  again  subjected  to  treatment,  but  this  time 
without  any  benefit.  I  examined  him  carefully  for 
symptoms  of  tabes  and  syphilis,  and  could  discover  nothing 
wrong  except  complete  loss  of  the  knee-jerk  in  both  sides 
and  paralysis  of  the  rectus  externus  muscle.  His  general 
health  was  excellent ;  yet  there  could  be  no  doubt  that  he 
was  in  the  first  stage  of  tabes. 

It  is  a  curious  circumstance,  and  one  that  is  of  some 
moment  in  the  question  with  which  we  are  now  occupied,  that 
both  tabes  and  syphilis  are  much  more  frequent  in  males 
than  in  females.  Fournier  finds  that  amongst  syphilitic 
patients  there  is  one  woman  to  nine  men ;  while  the  pro- 
portion in  tabes  is  about  one  woman  to  ten  men.  Where  tabes 


ETIOLOGY.  99 

occurs  in  women,  it  is  generally  in  the  lower  orders  of 
prostitutes,  or  in  poor  women  who  have  to  work  hard  in 
damp  shops.  Erb  has  seen  thirteen  tabid  women,  of  whom 
four  had  ajDparentlj  not  had  any  syphilis.  Three  others 
denied  having  had  it ;  but  the  first  of  these  latter  had  had 
three  miscarriages,  had  suffered  from  violent  headaches, 
and  four  of  her  children  had  died  young.  The  second  of 
the  three  had  had  two  miscarriages,  and  showed  cicatrices 
resulting  from  extensive  ulcerations  of  the  skin.  The 
husband  of  the  third  person  was  notoriously  syphilitic. 
Four  others  had  certainly  had  syphilis  ;  in  another  this  was 
highly  probable  ;  one  more  had  had  a  chancre.  This  is 
rather  a  heavy  indictment,  and  more  particularly  so  when 
we  remember  how  difficult  it  sometimes  is  to  discover 
syphilis  in  a  woman,  and  how  easy,  on  the  other  hand,  to 
overlook  it. 

While,  therefore,  an  overwhelming  amount  of  evidence 
speaks  for  a  causal  relation  between  syphilis  and  tabes,  we 
must  acknowledge,  on  the  other  hand,  that  cases  are  occa- 
sionally met  with  in  practice  where  tabes  and  syphilis  occur 
together,  and  where,  under  the  influence  of  specific  treat- 
ment, the  syphilitic  symptoms  on  the  skin  and  the  mucous 
membranes  are  improved  or  cured,  while  the  symptoms  of 
tabes  become  worse.  These  may  afterwards  improve  under 
the  influence  of  electricity  and  nitrate  of  silver.  Such  cases 
are  certainly  startling  ;  at  the  same  time  they  only  prove 
what  is  already  known,  viz.,  that  in  general  an  anti- 
syphilitic  treatment  has  only  little  influence  on  tabes  when 
this  has  become  firmly  established,  that  is,  after  the  second 
or  ataxic  stage  has  been  fairly  reached. 

In  many  cases  no  other  cause  but  syphilis  can  be  found 
for  the  evolution  of  tabes  ;  while  in  others  a  variety  of 
injurious  influences  appear  to  act  together  with  the  syphi- 
litic dyscrasia  in  leading  to  the  outbreak  of  the  complaint. 
The  principal  one  of  these  latter  is  unquestionably  the 
influence  of  cold.  Most  observers  are  agreed  on  this  point, 

H  2 


100  SCLEROSIS  OF  THE  SPIXAL  CORD. 

and  only  Fournier  appears  to  attach  little  importance  to  it. 
The  influence  of  cold  in  the  syphilitic  appears  occasionally 
to  act  as  the  exciting  cause,  while  in  the  non- syphilitic  it  is 
often  mentioned  as  the  only  cause  which  can  be  assigned. 

Case  14. — In  May,  1874,  I  was  consulted  by  a  patient, 
aged  fifty -nine,  married,  who  had  for  a  good  many  years  been 
in  business  in  Canada  as  a  provision-curer.  He  had  there  to 
pass  constantly  from  one  extreme  of  temperature  to  another, 
as  he  had  first  to  go  into  ice-houses  and  afterwards  into  the 
sun,  when  the  thermometer  in  the  shade  was  at  90°.  He 
had,  however,  also  had  syphilis  and  gonorrhoea  eighteen 
years  ago,  and  had  a  stricture  of  the  urethra,  which  gave 
him  a  great  deal  of  trouble.  Three  or  four  years  ago  he 
suddenly  lost  his  speech  and  became  paralysed  on  the  right 
side.  He  was  unconscious  for  a  fortnight,  and  then 
recovered.  At  present  he  has  the  true  gait  of  ataxy,  diffi- 
culty in  standing,  numbness  up  to  the  waist,  complete  loss  of 
sexual  power,  but  not  of  desire,  and  constipation  of  the 
bowels.  He  can  generally  pass  his  water  in  a  small  stream, 
but  has  occasionally  attacks  of  retention,  when  the  catheter 
has  to  be  introduced.  The  symptoms  of  tabes  had  become 
-developed  within  the  last  three  years,  and  were  by  the 
patient  and  his  friends  attributed  to  the  chills  he  was  in 
the  habit  of  receiving  by  going  into  ice-houses.  Yet 
we  cannot  ignore  that  he  had  had  syphilis,  and  the  fact  of 
his  having  had  temporary  aphasia  and  hemiplegia,  in  addi- 
tion to  his  other  troubles,  speaks  strongly  for  the  specific 
character  of  all  his  nerve-symptoms. 

Case  15. — Another  case  in  which  the  influence  of  cold 
appeared  to  act  as  the  exciting  cause  of  tabes  in  a  syphilitic 
subject  was  that  of  a  merchant,  aged  thirty,  single,  who 
consulted  me  in  January,  1873.  He  had  led  a  very  wild 
life,  and  had  syphilis  badly  four  years  ago.  He  consulted, 
amongst  others,  Professor  Lewin,  of  Berlin,  and  was  treated 
by  him  with  subcutaneous  injections  of  perchloride  of  mer- 
cury for  a  month,  after  which  all  symptoms  of  syphilis  left 


ETIOLOGY. 


101 


him.     He  spent  the  autumn  of   1870  at  Brighton,  and  was 
advised  to  take   sea-baths  very  late  in  the  season.     After 
this   he  first   began  to   feel   shooting   pains   in   the   lower 
extremities,  more  particularly  the   right  leg,  and  had  diffi- 
culty in   walking,   with   sluggishness   of   the  bladder   and- 
constipation  of  the  bowels.     Romberg's  symptom  was  pre- 
sent.    He  remained  for  some  time  under  my  care  and  I  had 
the  opportunity  of   satisfying   myself   that  the  syphilitic 
taint  was  by  no  means  eradicated  from  his  system,  as  he 
would  occasionally  for  weeks  together  have  specific  erup- 
tions on  different  parts  of  the  body,  such  as  ulceration  of 
the  tongue  and  of  the  penis. 

A  singular  case  in  point  is  that  of  a  Russian  officer 
who  acquired  a  chancre  while  serving  with  the  army 
in  the  Caucasus,  and  treated  the  sore  with  the  applica- 
tion of  what  he  called  "  snow-poultices "  !  Soon  after- 
wards he  felt  a  shooting  pain  in  the  groin,  scrotum, 
sacrum,  and  left  leg,  which  induced  him  to  apply  to  a 
surgeon.  He  now  underwent  treatment  by  inunction, 
which  appeared  to  be  successful  for  the  time.  Three 
years  afterwards,  however,  he  was  obliged  to  stand  in  the 
water  for  a  couple  of  hours,  and  then  felt  almost  at  once 
the  same  pain  in  the  left  leg  and  other  parts  which  he  had 
had  on  applying  the  snow.  Shortly  after  this  exposure 
had  taken  place,  double  vision,  constriction  of  the  chest, 
and  other  symptoms  of  tabes  supervened. 

The  influence  of  exposure  to  cold  is  no  doubt  to  a 
great  extent  instrumental  in  causing  the  numerous  cases 
of  tabes  which  occur  after  campaigns.  When  the  Austrians 
had  lost  the  battle  of  Sadowa,  they  had  in  their  precipi- 
tate retreat  to  cross  the  river  Elbe  ;  and  it  is  related  that 
amongst  those  who  had  to  flee  for  their  lives,  and  were 
thoroughly  wetted  on  that  occasion,  an  unusual  number 
of  cases  of  this  malady  occurred.  Romberg  mentions  that 
the  disease  was  rife  during  the  great  French  wars  in  the 
commencement  of  this  century.     A  large  number  of  cases 


102  SCLEROSIS  OF  THE  SPINAL  COKD. 

appear  also  to  have  occurred  in  the  celebrated  free-corps 
commanded  by  Major  Von  Liitzow  in  the  German  war 
of  hberation,  in  1813,  when  that  troop  of  irregular  horse 
underwent  the  most  extraordinary  fatigues  in  incessantly 
harassing  the  outposts  of  the  French  armies.  After  the 
war  in  Hungary  in  1849,  and  the  French  campaign  in 
Mexico,  similar  results  have  been  observed.  In  cam- 
paigns, however,  the  influence  of  cold  is  only  one  of  the 
factors ;  syphilis,  over-exertion  by  forced  marches,  and 
excesses  of  various  kinds  play,  probably,  quite  as  im- 
portant a  part  in  the  production  of  the  disease  as  cold. 

In  ordinary  every-day  life  the  influence  of  cold  in  pro- 
ducing tabes  is  observed  chiefly  in  persons  who  sleep  in 
newly  built  houses,  or  out  of  doors,  or  in  damp  bed- 
rooms ;  who  work  in  cold,  draughty  workshops  or  offices, 
or  as  agricultural  labourers  in  the  fields.  Tabes  seems 
occasionally  to  spring  from  frost-bite.  Exposure  to  cold 
also  has  a  most  prejudicial  influence  after  the  disease 
has  become  developed.  It  often  gives  a  fresh  impetus 
to  the  morbid  process,  and  renders  the  patients  more  use- 
less and  helpless  than  they  were  before. 

Case  16. — This  circumstance  was  well  shown  in  the  case 
of  a  merchant,  aged  forty,  a  widower,  who  consulted  me 
in  October,  1873.  He  had  had  gonorrhoea  many  times, 
and  syphilis  twenty  years  ago.  He  had  infected  his  wife 
and  only  child.  About  twelve  months  ago  he  had  a 
sudden  attack  of  double  vision,  and  began  to  suffer  from 
spermatorrhoea  and  lightning  pains  through  the  legs.  He 
consulted  a  quack,  who  told  him  that  "  his  blood  was  too 
hot,"  and  advised  him  to  walk  with  his  naked  feet  on 
the  bare  floor  for  half  an  hour  every  evening.  After  the 
patient  had  done  this  a  few  times,  he  rapidly  lost 
the  use  of  his  legs,  and  was  now  totally  unable  to  walk 
or  to  stand,  but  managed,  with  crutches,  to  walk  a  maxi- 
mum of  three  hundred  yards.  He  still  could,  when  sitting 
on  a  chair,  cross  one  leg  over  the  other,    and  move   the 


ETIOLOGY.  103 

legs  in  bed  quite  easily  in  all  directions.  The  bladder  was 
extremely  sluggish,  the  bowels  confined,  and  the  soles  of 
the  feet  completely  bennmbed. 

The  next  cause  which  is  of  influence,  as  exciting  the 
development  of  tabes,  is  over-exertion.  Experimental  over- 
stimulation of  the  muscles  in  animals,  by  long-continued 
faradisation,  has  led  to  paralysis  of  their  limbs,  as  seen  by 
Vulpian,  Brown- Sequard,  and  others  ;  and  it  is  easy  to 
understand  how  over-exertion,  either  in  walking  or  other 
ways,  should  exhaust  the  vital  power  of  the  spinal  cord. 
This  is  more  particularly  the  case  with  the  syphilitic,  while 
in  otherwise  healthy  persons  it  is  more  rare  ;  yet  it  was 
the  only  cause  which  could  be  discovered  in  the  following 
case  : — 

Case  17. — A  merchant,  aged  fifty,  consulted  me  in 
November,  1871.  He  had  for  a  number  of  years  been  en- 
gaged in  mining  operations  in  South  America,  which  en- 
tailed a  great  deal  of  going  down  on  ladders  and  crawling 
on  niches  in  rocks,  at  a  depth  of  upwards  of  a  thousand 
feet.  He  first  felt  weakness  in  the  legs  seventeen  years 
ago,  after  he  had  done  "  an  unusually  hard  job  "  of  this 
kind.  He  went  on  with  his  work,  however,  but  gradually 
got  worse,  and  about  four  years  ago  was  recommended  to  take 
hot  mineral  baths  in  South  America,  after  which  the  disease 
appeared  to  make  more  rapid  progress.  When  I  saw  him, 
symptoms  of  tabes  were  marked  in  both  upper  and  lower 
extremities,  and  there  was  also  a  considerable  amount  of 
wasting  in  the  muscles  of  the  hands.  He  had  never  had 
syphilis. 

The  following  is  another  case  in  point  : — 

Case  18. — In  June,  1874,  I  was  consulted  by  a  young 
gentleman,  aged  twenty,  who  was  then  reading  for  the  bar, 
and  was  chicken-breasted  and  hunchbacked,  but  had  been 
pretty  well  until  the  summer  of  1873,  when  he  went  to 
the  Vienna  Exhibition,  where  he  was  walking  and  stand- 
ing about  all   day  long.     After  some  time   spent  in  this 


104  SCLEROSIS  OF  THE  SPINAL  CORD. 

manner,  lie  began  to  feel  great  numbness  in  the  feet  and  legs, 
which  gradually  spread  upwards  to  the  waist.  He  was 
also  very  much  troubled  with  a  feeling  of  tightness  round 
the  chest.  Symptoms  of  catarrh  of  the  bladder,  with  great 
irritability  of  the  viscus,  then  appeared,  and  the  patient 
gradually  got  so  weak  on  his  legs  that  he  had  to  give 
up  walking  altogether.  At  present  he  was  totally  unable 
to  walk  without  assistance,  yet  had  not  the  least 
difficulty  in  moving  his  legs  in  bed,  and  showed  con- 
siderable muscular  force  in  resisting  attempted  flexion  of 
the  knees.  He  had  completely  lost  the  power  over  the 
bladder,  and  was  obliged  to  introduce  the  catheter  some- 
times every  hour,  more  especially  in  the  night,  when  he 
could  never  sleep  properly  on  account  of  constant  calls 
to  pass  his  water.  The  urine  was  ammoniacal.  and  con- 
tained a  large  quantity  of  muco-pus.  There  were  no 
symptoms  of  tabes  above  the  waist.  The  patient  denied 
having  ever  suffered  from  gonorrhoea  or  syphilis,  or  been 
much  exposed  to  cold,  and  attributed  his  malady  entirely 
to  the  over-exertion  which  has  been  mentioned. 

Accidents  appear  occasionally  to  lead  to  tabes,  with- 
out any  syphilitic  infection  or  any  other  cause  having  pre- 
viously occurred.  This  question  has  recently  been  studied 
by  Petit,^  who  has  collected  forty-seven  cases,  and  con- 
cludes that  injury  to  the  spine,  whether  direct  or  indirect,, 
by  falls  on  the  back,  the  seat,  or  the  feet,  may  cause  a  con- 
cussion of  the  cord,  and  subsequently  lesions,  which  may 
become  the  starting-point  of  a  chronic  myelitis,  showing 
the  symptoms  of  tabes.  He  thinks  that  more  especially 
in  persons  predisposed  to  sclerosis  in  general,  such  as 
the  gouty,  the  syphilitic,  and  the  alcoholised,  injuries  at 
a  distance  from  the  spine  may  over-excite  the  cord,  and  lead 
to  the  development  of  tabes  ;  that  they  may  aggravate  the 
existing  disease,  or  cause  a  relapse  where  it  has  been 
cured. 

1  "Revue  Mensuelle,"  Paris,  March,  1879. 


ETIOLO&Y.  105 

I  am  inclined  to  agree  with  Petit's  views,  from  having 
had  several  cases  under  my  care  in  which  a  severe  accident 
was  the  onlj  cause  which  could  be  ascertained. 

Case  19. — In  June,  1882,  I  had  a  patient,  aged  fifty, 
under  my  care  at  the  hospital,  who  had  been  a  digger 
in  Australia,  and  had  on  one  occasion  been  buried  in  a 
mine  for  several  hours.  This  occurred  three  years  ago. 
A  few  days  after  this  accident,  the  first  shocks  of  light- 
ning pains  appeared  in  the  right  leg  ;  and  twelve 
months  before  coming  under  my  care,  ataxy  of  gait,  with 
other  characteristic  symptoms,  began  to  be  perceptible. 
The  patient  denied  any  syphilitic  infection. 

In  other  cases  we  find  accidents  mentioned,  together  with 
syphilis,  a  wild  life,  and  other  causes  :  — 

Case  20. — An  ofiicer,  aged  forty-three,  married,  but  child- 
less, consulted  me  in  October,  1880.  He  had  been  mastur- 
bating as  a  boy,  and  led  a  very  wild  life  later  on.  In 
1864  he  had  a  chancre,  and  syphilitic  manifestations  had 
been  breaking  out  from  time  to  time  ever  since.  He  had 
lately  suffered  from  an  obstinate  syphilitic  ulceration  in  the 
legs.  He  had  also  had  a  severe  accident  while  hunting. 
In  1877,  i.e.,  thirteen  years  after  the  primary  affection,  he 
had  the  first  symptoms  of  tabes,  viz.,  double  vision,  neuralgic 
pains  in  legs  and  arms,  incontinence  of  urine,  and  loss 
of  sexual  power.  On  examination  he  showed  Westphal's, 
Romberg's  and  Argyll-Robertson's  symptoms  ;  he  stated 
that  he  passed  his  water  habitually  into  bed,  and  that, 
although  he  was  completely  impotent,  he  still  had  sexual 
desire.  The  walk  was  ataxic,  but  he  could  still  walk  for 
ten  or  fifteen  miles  at  a  time.  There  was  no  affection  of 
sensibility  in  any  part  of  his  body. 

The  following  case  shows  a  combination  of  syphilis,  ex- 
cesses in  smoking,  drinking  and  sexual  indulgence,  two 
several  accidents,  and  habitual  exposure  to  cold  : — 

Case2\. — A  chemist's  assistant,  aged  thirty-six,  single, 
consulted  me  in  November,  1881.  He  had  for  years  led  a  very 


106  SCLEROSIS  OF  THE  SPINAL  CORD. 

wild  life,  and  exceeded  greatly  in  drinking,  smoking,  and 
sexual  intercourse.  Ten  years  ago  he  had  a  sore  which  was 
presently  followed  by  a  bubo  and  roseola,  but  no  other  symp- 
toms of  infection.     Four  or  five  years  ago  he  had,  on  two 
several  occasions,  fallen  from  his  horse.     He  had  also  been 
kept  very  much  exposed  to  cold  in  a  shop,  where  no  fire  was 
in  winter  and   draughts  were  incessant.      Three  years  ago, 
when  at  a  cricket  match,  he  felt  that  he  could  not  run  well, 
and  suddenly  staggered  and  fell  down.     Ever  since  that 
time  he  has  had  great   difiiculty  in  walking.     Two  years 
ago  he  had  double  vision,  but  only  for  a  short  time.   Shoot- 
ing pains  in  the  legs  then  came  on,  which  were,  however, 
not  severe  ;  and  at  present  he  complains  more  of  pain  in 
the  left    shoulder,    which   is    apt   to    come   and   go  quite 
suddenly.     Going  down  stairs  is  most  awkward,  while  he 
manages    to    go    upstairs     tolerably    well.       Romberg's, 
Westphal's,  and  Argyll-Eobertson's  symptoms  are  marked. 
He  suffers  from  constipation  of  the  bowels  and  incontinence 
of  the  urine  ;  and  the  sexual   power  is  gone.     There  is 
considerable  diminution  of  sensibility  in  the  sphere  of  the 
right  ulnar  nerve  ;  but  none  in  the  left.     The  muscles  of 
the  balls  of  both  thumbs  are  greatly  wasted,  and  the  patient 
has    on   this    account    great    difiiculty   in    writing.     The 
interossei  are  also  somewhat  wasted.   The  electric  reactions 
of  the  wasted  muscles  are,  however,  normal.     The  grasp 
of  the  dynamometer  was  only  60°  with  the  left,  and  80°  with 
the  right  hand. 

I  saw  this  patient  again  in  June,  1883,  when  there  were, 
in  addition,  symptoms  of  optic  atrophy  in  the  right  eye.  The 
difficulty  of  vision  had  only  become  perceptible  about  a  fort- 
night ago,  when  "  a  dark  cloud  seemed  to  become  settled 
at  the  top  of  the  field  of  vision,  and  he  was  unable  to  dis- 
tinguish with  that  eye  anything  above  the  eyebrow." 
There  was  achromatopsia  on  the  right,  but  not  on  the  left 
eye.  The  right  eye  showed  the  peculiar  white  condition 
of   the  nerve,   but  the  left  appeared  normal  by   ophthal- 


ETIOLOGY.  ,  107 

moscopic  investigation,  and  also  had  the  proper  acuity  of 
vision. 

In  the  next  case  there  was  a  combination  of  syphilis  and 
accident,  and  the  symptoms  of  tabes  were  rather  blurred. 

Case  22. — In  May,  1872,  I  was  consulted  by  a  surgeon, 
aged  thirty -two,  who  had  five  years  ago  fallen  with  his  horse. 
Until  then  he  had  enjoyed  perfect  heath.  He  received  no 
injury  except  slight  bruises,  but  felt  so  shaken  that  he  could 
hardly  do  anything  for  about  a  week,  after  which  he  felt 
much  better.  He  then  had  to  make  a  hurried  journey  to 
Cannes,  travelled  night  and  day  for  a  week,  and  smoked  a 
great  many  bad  cigars.  On  his  return  home  he  felt  "  very 
seedy,  as  if  he  was  going  to  have  a  serious  illness."  From 
that  time  a  number  of  secondary  syphilitic  symptoms  made 
their  appearance,  although  he  never  to  his  knowledge  had 
a  primary  sore.  While  in  France  he  had  had  no  sexual 
intercourse  whatever.  Psoriasis  appeared  over  the  greater 
part  of  the  body  ;  then  rupia,  ulcerated  sore  throat,  and 
coppery  blotches  on  various  parts.  At  the  same  time  he 
had  frightful  attacks  of  headache,  with  giddiness  and  formi- 
cation in  the  lips.  He  then  took  perchloride  of  mercury 
and  potassic  iodide,  but  without  benefit ;  one  symptom  suc- 
ceeded another,  until  he  was  so  weak  that  he  could  hardly 
stir.  Then  came  a  dull  pain  in  the  lumbar  region,  which 
was  very  much  increased  by  riding  or  walking.  This  was 
followed  by  difiiculty  to  urinate,  pins  and  needles  in  the 
skin  over  the  abdomen,  and  loss  of  sensation  and  motion  in 
the  lower  extremities,  with  loss  of  control  over  the  bladder 
and  rectum.  He  was  then  confined  to  his  bed  for  six 
weeks,  and  eventually  sent  to  Aix-la-Chapelle,  where, 
under  the  care  of  Dr.  Wetzlar,  he  underwent  a  course  of 
mercurial  inunction  and  baths. 

At  present  he  was  obliged  to  use  the  catheter  habitually 
for  emptying  the  bladder,  and  had  no  control  over  the 
rectum  whenever  the  evacuation  was  loose.  Formerly  the 
urine  was  spasmodically  ejected  when  he  walked,  and  he 


108  SCLEROSIS  OF  THE  SPINAL  CORD. 

had  no  control  whatever  over  the  rectum.  He  had  more 
power  in  the  legs.  Formerly,  if  he  tripped  ever  so  lightly, 
he  was  sure  to  fall,  while  now  he  rarely  tripped,  and 
could  generally  save  himself  from  falling.  In  fine  weather 
he  could  now  walk  four  or  five  miles  ;  but  if  it  was  damp 
or  thundery,  the  power  of  walking  would  leave  him  alto- 
gether. He  had  several  times  had  an  enlargement  of  the 
left  testicle,  which  was  generally  reduced  by  taking  potassic 
iodide,  but  on  one  occasion  an  abscess  formed  and  burst. 
He  was  now  getting  very  fat  and  weak,  and  found  it  an 
effort  to  do  anything  ;  but  when  breathing  mountain  air  he 
was  much  better  able  to  exert  himself. 

A  similar  combination  of  accident  and  syphilis  was  seen 
in  the  following  case  : — 

Case  23. — A  bookseller,  aged  thirty -three,  single,  con- 
sulted me  in  October,  1876.  He  had  had  syphilis  about 
ten  years  ago.  Five  years  ago  he  had  a  fall  from  a  horse, 
and  was  pitched  down  head  foremost,  and  made  a  somer- 
sault in  the  air.  He  felt  giddy,  saw  sparks  flying  before 
his  eyes,  but  recovered  himself  almost  immediately,  and 
walked  home  by  the  side  of  the  horse.  About  six  months 
afterwards  he  began  to  suffer  from  lightning  pains  and  loss 
of  control  over  the  limbs.  He  has  now  lost  flesh  to  such 
an  extent  that  his  legs  are  mere  sticks  ;  and  the  same  is 
the  case  in  the  arm  ;  there  is  no  biceps  left ;  while  in 
the  forearm  there  is  more  muscle  and  more  power.  The 
gait  is  of  the  purely  ataxic  type  ;  the  patient  cannot  walk 
at  all,  except  when  supported,  and  is  worse  in  the  dark. 
There  is  loss  of  control  over  the  bladder  and  rectum,  and 
the  sexual  power  and  desire  are  gone.  He  suffers  also 
very  much  from  indigestion,  and  has  a  very  feeble  pulse. 
"  When  the  liver  is  out  of  order,  the  pain  becomes  much 
worse "  (no  doubt  an  instance  of  the  coincidence  of 
"  gastric  crises  "  with  bouts  of  lightning  pain). 

Venereal  excesses  have  already  been  mentioned  in  several 
of  the  cases  which  I  have  just  shortly  related.     Duchenne 


ETIOLOGY.  109 

has  seen  a  case  in  which  "  frantic  masturbation  "  appeared 
to  be  the  cause.  Sexual  excesses  generally  coincide  with 
excesses  in  drinking,  smoking,  and  the  acquisition  of 
syphilis,  and  it  is  therefore  difficult  to  apportion  the  exact 
degree  of  influence  which  the  former  agent  may  possess.  I 
have  not  seen  a  single  case  in  which  venereal  excesses  alone 
could  be  looked  upon  as  the  cause.  In  the  female  sex,  tabes 
is  chiefly  found  in  prostitutes  ;  and  in  them  the  three  agents 
of  syphilis,  excesses,  and  drink  probably  rank  in  import- 
ance in  the  order  in  which  they  have  just  been  stated  in 
the  production  of  the  malady.  Exposure  to  cold  may  in 
some  instances  be  added  to  it.  Lancereaux  ^  has  noticed 
that  tabes  occurs  amongst  girls  in  Paris  who  work  the  sew- 
ing-machine with  the  foot.  These  women  are  extremely 
hard  worked,  as  many  of  them  have  to  continue  at  their 
work  from  six  a.m.  until  midnight.  The  constant  move- 
ment of  the  foot  appears  to  excite  the  sexual  organs,  which 
become  so  hot  and  congested  that  the  women  are  obliged  to 
wash  the  parts  frequently  with  cold  water.  It  is  assumed 
that  the  excessive  functional  excitement  starting  in  the 
sexual  organs  provokes  through  the  centripetal  nerves 
irritative  reaction  in  the  parts  whose  function  it  is  to  re- 
ceive those  impressions,  and  that  it  is  more  the  prolonged 
and  injurious  action  of  a  more  or  less  abnormal  sexual  ex- 
citement on  the  spinal  cord  than  syphilis  which  produces 
tabes.  I  am  unable  to  agree  with  this  opinion.  I  have 
seen  in  hospital  practice  cases  of  tabes  in  London  working 
women  who  had  to  use  the  sewing-machine  which  is 
worked  with  the  foot,  and  have  inquired  amongst  them 
whether  this  has  the  effect  on  the  sexual  organs  mentioned 
by  Lancereaux.  They  did  not  seem  to  understand  the 
bearing  of  my  inquiry,  although  they  happened  to  be  very 
intelligent  persons ;  but  attributed  their  illness  to  having 
worked    in    damp  workshops  and  amongst  generally  un- 

'  "  Transactions    of    the    International    Medical    Congress,"    1881, 
vol.  ii.,  p.  42. 


110  SCLEROSIS  OF  THE  SPINAL  CORD. 

healthy  surroundings.  None  of  them  had  apparently  had 
syphilis.  The  French  working  girls  are  probably  sexually 
more  excitable  than  the  English  ;  a  similar  difference  being 
seen  in  the  development  and  aspects  of  hysteria  in  the  two 
countries. 

The  influence  of  dnnh  alone  does  not  seem  to  be 
great.  A  French  army  surgeon  (Case  24),  who  consulted 
me  in  December,  1882,  for  a  very  painful  form  of  tabes, 
with  severe  laryngeal  crises,  mentioned  in  his  history  mas- 
turbation early  in  life  ;  syphilis,  sexual  excesses,  and 
ahsynthe-drinling  later  on.  The  influence  of  drink  in  the 
parent  was  the  only  cause  which  I  could  discover  in  the  case 
of  a  Swedish  gentleman  (Case  26),  who  was  sent  to  me  by 
Dr.  Allan,  of  Hyde  Park  Terrace,  in  January  last.  He  had 
led  an  exemplary  life,  had  never  had  anything  to  do  with 
women,  not  met  with  accidents,  nor  been  subject  to  ex- 
posure or  unfavourable  influences  of  any  kind.  His  father, 
however,  had  been  an  inveterate  drunkard,  and  had  died  in 
a  fit  of  dninkenness  at  thirty-nine  years  of  age.  It  is  there- 
fore not  at  all  improbable  that  this  patient  may  have  been 
conceived  while  his  father  was  in  a  state  of  intoxication — a 
circumstance  which  is  known  to  give  rise  to  epilepsy,  para- 
lysis, idiocy,  and  insanity  in  the  offspring,  and  is  probably 
Instrumental  in  inducing  the  form  of  tabes  which  is  known 
as  Friedreich's  disease. 

The  influence  of  tobacco-smoMng  is  probably  not  great ;  ex- 
cessive smoking,  however,  was  mentioned  to  me  as  the  cause 
of  his  illness  by  a  merchant  (Case  26),  aged  thirty-one, 
married,  and  father  of  three  children,  who  consulted  me  in 
March,  1874.  He  said  that  he  had  for  years  smoked  all  day 
long  without  interruption,  and  habitually  consumed  as  much 
as  two  ounces  of  birds-eye  per  diem.  He  had  never  had 
syphilis,  nor  been  subject  to  any  other  unfavourable 
influence.  His  present  illness  dated  from  three  years  ago, 
when  his  legs  became  very  weak  and  numb.  He  now 
feels  "  as  if  he  had  no  legs,  but  only  two  sticks."     He  has 


ETIOLOGY.  Ill 

the  characteristic  difficulty  in  standing,  the  ataxic  gait, 
loss  of  sexual  power,  and  of  control  over  the  bladder  and 
bowels. 

The  acute  infectious  diseases  appear  to  have  but  little  in- 
fluence in  producing  tabes.  I  have  never  seen  a  case 
occurring  subsequently  to  typhoid  fever,  small-pox,  ery- 
sipelas, measles,  etc.  ;  and  only  one  after  jungle  fever. 

Case  27. — This  was  the  case  of  an  officer,  aged  thirty -five, 
single,  who  was  sent  to  me  by  Dr.  Henry  Savage,  in  May, 
1865  ;  he  had  been  fourteen  years  in  India,  and  enjoyed 
good  health  until  about  twelve  months  ago,  when  he  was 
seized  by  jungle  fever,  which  proved  most  intractable  ;  and 
he  never  recovered  his  health  thoroughly  afterwards.  He 
suffered  much  from  indigestion  and  nervousness,  but  more 
particularly  from  difficulty  in  walking.  I  found  the  gait 
typically  ataxic.  He  was  apt  to  lose  his  balance,  and  had 
frequently  fallen  down  lately  ;  felt  quite  helpless  in  the 
dark,  was  very  nervous  on  going  down  stairs,  and  had  a 
peculiar  feeling  in  walking,  as  if  the  ground  rose  with 
him,  and  he  were  walking  on  elastic  springs.  The  right 
pupil  was  larger  than  the  left,  but  there  were  no  ophthal- 
moscopic signs  of  optic  atrophy.  He  had  had  no  syphilis, 
and  his  illness  could  only  be  attributed  to  the  effects  of  the 
fever.  There  was  a  slight  but  perceptible  swelling  of  the 
spleen. 

Cases  of  acute  tabes  have  been  seen  in  connection  with 
lepra  and  pellagra.  After  ague,  Kahler  and  Pick  have 
noticed  absence  of  the  knee-jerk,  which  eventually  re- 
turned when  the  patient's  health  was  restored.  Poisoning 
with  lead,  arsenic,  barium,  and  other  metals  seems  also 
occasionally  to  lead  to  acute  tabes  ;  but  this  part  of  the 
subject  is  as  yet  hardly  explored. 

In  some  few  patients,  finally,  we  do  not  find  any  other 
cause  except  the  necrotic  constitution  as  inherited  from 
parents  who  have  been  subject  to  epilepsy,  paralysis, 
insanity,  hysteria,   chorea,  megrim,  malformation   of  the 


112  SCLEROSIS  OF  THE  SPINAL  CORD. 

skull,  or  simply  to  excessive  excitability  of  the  nervous 
system,  as  sliown  by  habitually  violent  manners,  out- 
bursts of  passion,  an  odd  or  eccentric  behaviour,  etc. 
Eulenburg  ^  mentions  the  case  of  a  patient  in  whose  family 
there  had  been  direct  transmission  of  tabes  from  father 
to  son  for  four  generations.  Trousseau^  has  known 
a  family  in  whom  one  member  was  affected  with  tabes 
while  others  were  subject  to  monomania,  hypochon- 
driasis, and  spermatorrhoea  ;  another  patient  with  tabes 
had  an  aunt  and  an  uncle  who  were  both  insane,  a  brother 
who  had  also  tabes,  and  another  brother  who  had  hemi- 
plegia ;  and  a  third  patient,  who  had  tabes,  was  the  son  of 
a  father  who  had  committed  suicide,  and  had  himself  two 
sons,  one  of  whom,  although  not  insane,  was  in  the  habit 
of  uttering  piercing  shrieks  all  day  long,  "  impelled  thereto 
by  an  irresistible  force,"  while  the  second  had  a  singular 
form  of  muscular  "  tic."  Vidal,  quoted  by  Topinard,^  re- 
ports the  case  of  a  man  with  tabes,  whose  sister  died  in  a 
madhouse,  one  of  whose  daughters  died  in  a  fit,  while 
another  suffered  from  incontinence  of  the  urine ;  the 
patient  himself  was  affected  by  congenital  nystagmus.  In 
a  patient  of  Gubler's,  the  maternal  grandmother  and  a 
paternal  uncle  had  died  of  hemiplegia,  while  his  mother 
had  long  been  hysterical,  but  was  then  alive  and  well,  at 
eighty  years  of  age. 

The  inflaence  of  the  neurotic  constitution,  however,  is 
more  particularly  seen  in  that  peculiar  form  of  tabes  which 
is  known  as  Friedreich's  disease  (p.  65),  or  hereditary 
ataxy.  Friedreich's  own  observations,  which  have  since 
been  supplemented  by  those  of  others  equally  striking, 
extended  over  three  sets  of  cases,  viz.,  first  a  brother 
and  sister,  whose  father  had  been  a  notorious  drunkard  ; 

*  Zoc.  cit.,  p.  458. 

2  "  CHnique  Medicale  de  I'Hotel  Dieu  de  Paris,"  vol.  ii.,  p.  610. 
Cinquieme  edition,     Paris,  1877. 

>  "  De  I'Ataxie  Locomotrice,"  p.  444.     Paris,  1864. 


ETIOLOGY.  113 

■second,  three  sisters,  whose  parents  were  industrious  and 
healthy  ;  and,  finally,  three  sisters  and  one  brother,  whose 
father  seems  to  have  been  a  somewhat  remarkable  char- 
acter, as  he  combined  the  functions  of  tailor,  barber,  and 
musician,  drank  heavily,  led  a  fearfully  immoral  life,  and 
eventually  died  of  consumption.  The  wife  of  this  man 
was  bodily  healthy,  but  unusually  stupid ;  she  mentioned, 
however,  as  a  fact  that  all  the  four  children  had  been  con- 
ceived while  the  father  was  in  a  state  of  intoxication.  I 
have  already  (p.  110)  spoken  of  the  case  of  a  patient  now 
under  my  observation,  in  which  this  appeared  to  be  the 
only  cause  of  the  tabes  which  could  be  ascertained. 

Carre  ^  has  given  the  history  of  a  family  in  which  the 
grandmother,  the  mother,  and  all  her  relations,  who 
numbered  eight,  as  well  as  seven  children  and  one  cousin, 
in  all  eighteen,  were  affected  by  tabes.  Of  the  seven 
children,  three  were  dead  ;  one  was  deaf,  and  crawled 
about  on  all  fours  ;  while  the  cousin  was  blind.  In 
1872,  Dr.  Carpenter,  of  Croydon,  showed  to  the  Medical 
Society  of  London  two  girls  suffering  from  what  he  called 
^'  muscular  angesthesia,"  but  what  was  really  Friedreich's 
disease ;  and  later  on  a  third  member  of  the  same  family 
became  affected. 

Dreschfeld  ^  has  described  a  family  where  five,  viz.,  three 
brothers  and  two  sisters,  out  of  fifteen,  were  tabid  ;  and 
Gowers,^  one  in  which  five  out  of  eight  had  the  same 
disease,  viz.,  one  girl  and  four  brothers.  None  of  these 
latter  patients  had  had  syphilis  or  inherited  syphilis  ;  but 
on  the  father's  side  there  was  a  long  history  of  insanity, 
while  the  mother  had  suffered  from  chorea  ;  and  the 
disease  commenced  in  all  the  patients  between  the  ages 
of  eighteen  and  twenty-one. 

'  "  De  I'Ataxie  Locomotrice  Progressive."     These  de  Paris,  1863. 
2  *'  Liverpool  and  Manchester  Medical  Eeports,"  1876,  vol.  iv.  p.  93. 
^  "  Transactions  of  the  Clinical  Society  of  London,"  1881,  vol.  xiv. 
p.  1. 

I 


114  SCLEROSIS   OF  THE   SPINAL  COED. 

Walle,^  of  Wattwyl,  describes  two  cases  of  Friedreich's 
disease,  which  are  remarkable  from  having  begun  at  an  un- 
usually early  age.  Both  patients  were  males,  and  came  of 
a  family  of  seventeen  children,  of  whom  seven  died  in  in- 
fancy. The  father  had  been  healthy,  but  the  mother  had 
been  temporarily  insane  ;  and  there  had  been  no  other 
nervous  diseases  in  the  family.  The  eldest  of  the  two 
brothers,  now  twenty  years  of  age,  was  in  his  seventh  year 
taken  with  difficulty  in  walking,  followed  presently  by 
awkwardness  in  the  use  of  the  upper  extremities.  He  had 
sometimes  pain  in  the  knees  and  legs,  although  not  of  the 
lightning  or  terebrating  character,  and  occasionally  head- 
ache and  vomiting.  At  present  there  was  curvature  of  the 
spine,  with  the  feet  in  equine  position,  and  dorsal  flexiou 
of  the  big  toes  ;  the  muscles  were  not  wasted,  and  showed 
considerable  power.  The  patient  was  awkward  in  taking 
hold  of  objects,  and,  on  closing  the  eyes,  could  not  put  a 
tumbler  to  his  mouth.  There  was  numbness  in  the  feet, 
and  sensibility  was  altogether  somewhat  reduced.  All  the 
deep  reflexes  were  absent.  There  was  slight  nystagmus, 
and  the  speech  somewhat  drawling.  In  walking,  the  ataxy 
was  so  severe  that  the  patient  could  not  attempt  it  without 
support. 

The  second  patient  was  twelve  years  old,  and  had  had 
difficulty  in  walking  since  h\B  fourth  year.  There  was  also 
lateral  curvature  and  commencing  equine  position  of  feet.. 
He  walked  like  one  who  is  drunk,  and  the  deep  reflexes 
were  absent.  Sensibility,  however,  and  the  use  of  the 
upper  extremities  were  not  interfered  with. 

Friedreich  thought  that  the  female  sex  was  more  liable 
to  the  affection  than  the  male,  as  seven  of  his  cases  oc- 
curred in  girls  and  only  two  in  boys  ;  but,  out  of  forty-six 
cases  which  I  have  collected,  thirty  occurred  in  boys  and  only 
sixteen  in  girls,  showing  a  decided  preponderance  of  the 

1  "  Correspondenzblatt  fiir  Schweizer  Aerzte,"  1883,  p.  145. 


ETIOLOGY.  Ho 

male  sex.  As  regards  age,  the  malady  coDimences  in  a  good 
many  cases  about  the  time  of  the  development  of  puberty, 
that  is,  between  twelve  and  seventeen  years  ;  and  in  con- 
nection with  this  it  is  useful  to  remember  that  Rokitansky 
has  found  great  tendency  to  venous  hypergemia  in  the 
spinal  canal  during  that  period  of  life.  The  general  ten- 
dency of  Friedreich's  disease  to  appear  at  an  early  time  of 
life  is  one  of  the  features  distinguishing  it  from  ordinary 
tabes,  which  usually  becomes  developed  between  thirty  and 
fifty  years  of  age. 

While,  therefore,  in  Friedreich's  disease,  and  also  in 
some  few  cases  of  ordinary  tabes,  a  neurotic  predisposition 
seems  undoubtedly  to  exist,  I  have  come  to  the  conclusion 
that  in  by  far  the  largest  majority  of  cases  of  ordinary  tabes 
the  fault  lies  more  with  the  individual  patient  than  with  the 
stock  from  which  he  came.  Hysteria  in  the  mother  I  have 
found  in  several  cases,  while  of  other  forms  of  nervous 
disease  in  parents  I  have  seen  singularly  little.  Yulpian 
states  that  a  special  predisposition  must  necessarily  exist 
for  the  development  of  tabes,  even  where  there  has  been 
syphilis  ;  for  why,  he  asks,  should  tabes  be  so  rare  when 
syphilis  is  so  frequent  ?  To  this  question  I  may  answer, 
first,  that  tabes  is  much  more  frequent  than  is  generally 
believed ;  and,  secondly,  that  many  persons  who  have 
acquired  syphilis  are  subjected  to  a  long  course  of  specific 
treatment,  and  therefore  escape  the  tertiary  affections 
which  might  otherwise  have  been  in  store  for  them.  On 
the  whole,  therefore,  there  is  only  a  slight  influence  of 
heredity  in  tabes  ;  on  the  other  hand,  the  mode  of  life 
adopted  by  the  individual  plays,  no  doubt,  a  considerable 
part  in  the  production  of  the  disease.  Persons  who  have 
had  syphilis  will  be  more  likely  to  acquire  tabes  if  they 
commit  afterwards  excesses  in  sexual  indulgence,  the 
pleasures  of  the  table,  drinking  and  smoking,  and  lead  an 
irregular  and  exciting  kind  of  life. 

Fournier  finds   most   victims     of    tabes     amongst    the 

i2 


116  SCLEROSIS  OF  THE  SPINAL  COED. 

votaries  of  pleasure  in  large  cities.  Yet  syphilis,  drink, 
and  venereal  excesses  are  quite  as  mucli  at  work  in  small 
country  towns  as  in  Paris  and  London,  and  I  doubt  whether 
tabes  is  really  more  frequent  in  the  "great  centres  of 
civilisation."  I  have  seen  a  considerable  number  of  men 
who  had  emptied  to  the  last  dregs  the  cup  of  what  is 
called  "pleasure,"  and  who,  having  by  a  lucky  chance 
steered  clear  of  syphilis,  had  not  acquired  tabes.  Excesses 
without  syphilis  appear  to  lead  in  general  more  to  cerebral 
than  to  spinal  disease. 

Whether  any  particular  profession  is  more  exposed  to 
tabes  than  another  is  difficult  to  ascertain.  In  hospital 
practice  my  patients  have  been  firemen,  boatmen,  cabmen, 
coachmen,  policemen,  engine-drivers,  workers  in  drainage, 
railway  guards,  and  navvies  ;  and  amongst  women  those 
who  had  to  work  hard  and  long  in  damp  places,  more 
especially  upholsteresses,  waistcoat-makers,  laundresses,  etc. 
On  the  whole,  however,  tabes  appears  to  be  more  frequent 
in  the  higher  than  in  the  lower  strata  of  society  ;  and  this 
is  possibly  due  to  the  greater  mental  efforts  required  of  the 
former,  combined  with  anxiety  and  depressing  emotions  of 
various  kinds  which  affect  the  rich  more  than  the  poor, 
and  which  tend  to  lower  the  power  of  resistance  of  the 
nervous  centres  to  injurious  influences. 

Whether  acute  or  subacute  muscular  rheumatism  has  any 
influence  in  the  production  of  tabes,  as  has  been  stated, 
seems  very  doubtful.  Most  patients  call  the  lightning- 
pains  rheumatic,  and  come  with  an  apparent  history  of 
rheumatism,  which,  however,  does  not  bear  critical  investi- 
gation. The  same  may  be  said  of  our  old  friend,  the 
"  suppression  of  habitual  perspiration.^^  This  is  rather  more 
likely  to  be  owing  to,  than  productive  of,  the  disease.  A 
patient  who  was  sent  to  me  by  Mr.  Bickersteth,  of  Liver- 
pool, in  June,  1882  (Case  27),  ascribed  the  outbreak  of  the 
malady  to  a  bad  attack  of  diarrhoea,  which  he  had  had 
while  staying  at  Madeira ;  it  was  then  that  he  first  noticed 


ETIOLOGY.  117 

unsteadiness  in  walking,  which  the  doctor  there  thought 
to  be  owing  to  the  relaxing  climate.  On  inquiry,  I  found 
that  he  had  had  syphilis  very  badly  fifteen  years  ago.  He 
then  suffered  from  fearful  ulcerations  of  the  skin  and  sub- 
jacent tissues,  buboes  which  would  not  heal,  etc.,  for  about 
fifteen  months  after  the  primary  sore,  and  he  acknowledged 
having  been  insufficiently  treated  "  from  want  of  time  "  ! 
He  has  now  occasionally  crops  of  copper-coloured  spots 
appearing  on  his  skin  ;  on  the  whole,  however,  the 
"active "  manifestations  of  the  disease  have  ceased  for 
some  years  past.  At  present  he  shows  absence  of  knee- 
jerk  in  both  legs  ;  has  a  difiiculty  in  holding  and  expelling 
the  urine,  looseness  of  the  bowels,  diminished  sexual  desire 
and  power,  Romberg's  symptom,  ataxic  gait,  and  difficulty 
in  going  downstairs.  In  the  upper  extremities  the  mus- 
cular force  is  considerable,  as  he  squeezed  the  dynamometer 
to  160°,  yet  the  fingers  were  numb.  He  had  never  suffered 
from  lightning-pains  or  constriction  round  the  waist.  While, 
therefore,  the  disease  was  no  doubt  owing  to  syphilis, 
yet  the  attack  of  diarrhoea  may  have  aggravated  the  already 
existing  malady. 

We  are  on  much  firmer  ground  in  discussing  the  influence 
of  age  and  sex  in  the  production  of  tabes. 

With  regard  to  the  age  at  which  the  disease  is  most 
likely  to  break  out,  the  statements  of  several  observers  are 
devoid  of  value,  as  they  have  only  given  the  ages  at  which 
the  patients  came  under  care,  and  not  those  at  which  the 
first  symptoms  of  the  malady  appeared.  Thus  Topinard,^ 
who  has  tabulated  104  cases,  gives  the  following  list,  which 
is  also  objectionable  by  its  arrangement,  as  the  same  num- 
bers are  made  to  appear  at  the  beginning  and  the  end  of 
the  period  : — 

From  26  to  30  years  of  age  13  cases. 
„     30  „  35  ,,  11     ,, 

'  "  De  I'ataxie  locomotrice,"  p.  359.     Paris,  1864. 


118 


SCLEROSIS  OF  THE   SPINAL  CORD. 


From  35  to  40  years  of  age  20  cases. 
40  „  45  „  20     „ 

45  „  50  „  20     „ 

50  „  55  „  10     ,, 

55  „  60  „  6     „ 

60  „  65  „  3     „ 

At  75  years  in  1  case. 
This  list   only  applies    to  the  fully-developed   malady, 
when   the  patients  are  in   the    second    period.      Erb,^   on 
the  other  hand,  finds  the  beginning  of  the  malady — 
Between  11  and  20  years  in  3  cases. 
21    „    30       „        13     „ 
31    „    40       „        31     „ 
„         41    „    50       „        18     „ 
„         51    „    60       „  3     „ 

In  fifty-two  cases  in  which  I  have  been  able  to  ascertain 
as  nearly  as  possible  the  date  of  the  outbreak  of  the  disease, 
it  occurred — 

At  9  years  in  1  case. 
Between  20  and  29  years  in  9  cases. 
30    „    39       „        18     „ 
40    „    49       „        13     „ 
50    „    59       „        10     „       . 
At  60  years  in  1  case. 
My  youngest  patient  was  a  girl,   aged  nine   (Case  28), 
who  was  sent  to  me  by  Dr.  Horace  Dobell,  in  July,  1881. 
She  had  been   staying  at  the  seaside,  and  been  paddling 
a   good   deal   in   the    cold    water   with    her  naked   feet, 
which    was    the   only  cause    that    could  be    ascertained. 
After    a  time,   she    experienced    lightning    pains    in   dif- 
ferent parts   of  the  body,   which   were   short,   sharp,   and 
agonizing,   and  caused   her  to  scream  whenever   a   shock 
passed  through  her.      When  she  came    to  see  me,  these 


^  "  Kraiiklieiten  des  Riickenmarks  "  (in  Ziemssen),  voh  ii.,  p.  131 
Leipzig,  1878. 


ETIOLOGY.  119 

shocks  occurred  chiefly  in  the  left  knee,  where  a  stab- 
bing pain  was  felt  every  two  or  three  minutes.  The 
knee-jerk  was  absent  in  both  sides.  There  were  no  other 
symptoms  ;  and  she  did  not  appear  to  have  ever  been  sub- 
ject to  symptoms  of  inherited  syphilis.  The  pain  resisted 
the  use  of  nitrate  of  silver,  in  doses  of  one-eighth  part  of 
a  grain,  and  the  application  of  the  constant  current ;  but 
yielded  completely  to  the  use  of  ergot,  in  ten-minim 
doses  of  the  liquid  extract,  thrice  daily.  I  have  not  seen 
the  little  patient  since,  and  am  therefore  unable  to  say 
whether  the  patellar  reflex  has  returned. 

The  next  youngest  patient  with  tabes  (Case  29)  whom  I 
have  seen  was  an  omnibus-conductor,  aged  twenty-two, 
who  came  under  my  care  at  the  hospital  in  February,  1878. 
He  had  had  small-pox  ten  years  ago,  and  a  primary  sore 
when  seventeen  years  of  age.  He  appeared  to  have  had  no 
secondary  symptoms,  but  had  an  attack  of  hemiplegia  of 
the  left  side  two  and  a-half  years  ago,  being  then  in  his 
twentieth  year.  He  recovered  from  this  completely  in  three 
weeks.  In  June,  1877,  he  had  an  attack  of  double  vision, 
which  was  treated  at  Moorfields.  A  week  before  he  came 
to  the  hospital  he  suddenly  felt  pain  at  the  back  of  the 
head  and  down  the  neck,  and  a  curious  sensation  of  numb- 
ness in  his  face,  which  soon  afterwards  was  drawn  to  the 
side.  When  I  examined  the  patient,  there  were  all  the 
symptoms  of  paralysis  of  the  left  portio  dura  in  the  first 
portion  of  the  Fallopian  canal,  together  with  paralysis  of 
the  left  rectus  externus.  The  knee-jerk  ivas  absent  in 
both  sides.  There  could  be  no  doubt  that  it  was  a  case  of 
commencing  tabes  ;  but  it  was  diflicult  to  say  when  this 
affection  commenced,  and  whether  it  was  already  present 
when  the  patient  had  the  stroke  of  paralysis  at  nineteen 
years  of  age,  or  whether  the  attack  of  double  vision  at 
twenty-one  was  the  first  symptom  of  it.  An  examination 
of  the  knee-jerk  alone  at  the  earlier  period  of  his  illness 
could  have  settled  this  question. 


120  SCLEROSIS  OF  THE  SPINAL  CORD. 

Another  case  in  a  very  young  man  was  that  of  a 
lieutenant  in  the  Indian  army  (Case  30),  who  was  sent  to 
me  by  Mr.  Erichsen  in  April,  1872.  He  was  then  twenty- 
three  years  of  age,  and  had  contracted  syphilis  three  years 
ago.  He  had  had  an  indurated  chancre  and  bubo,  and  had 
subsequently  suffered  from  severe  ulceration  in  the  region 
of  the  left  shoulder,  and  from  iritis.  Symptoms  of  tabes 
appeared  about  twelve  months  ago,  that  is,  at  twenty- 
two  years  of  age,  and  were  more  marked  in  the  left  than 
in  the  right  side  cf  the  body.  He  was  much  troubled 
with  numbness,  particularly  in  the  left  foot  ;  had  difficulty 
in  standing  on  the  left  foot,  while  he  could  stand  tolerably 
well  on  the  right ;  staggered  when  he  was  requested  to 
close  his  eyes  ;  and  had  much  difficulty  in  walking  slowly, 
while  he  could  walk  fast .  better.  He  then,  however,  had 
to  manoeuvre  considerably,  and  showed  the  characteristic 
gait  of  ataxy  in  the  most  unmistakeable  manner. 

From  the  table  which  I  have  just  given,  it  appears  that 
tabes  is  most  prone  to  break  out  between  thirty  and  fifty 
years  of  age.  The  ages  of  the  same  patients  at  the  time 
they  came  under  my  care  were  as  follows  : — 


At    9  years 

in 

1 

case. 

From  20  to  29 

years  in  3 

cases. 

„     30  „  39 

}} 

12 

jj 

„     40  „  49 

33 

21 

jj 

„     50  „  59 

>J 

11 

}i 

„     60  „  69 

JJ 

3 

3? 

At  72  years 

in 

1 

case. 

Tabes  is,  therefore,  in  general  a  disease  of  the  prime  of 
life. 

The  following  table  is  given  by  Eulenburg  : — 

The  disease  appeared  at  9  years  in  1  case. 
„  „    up  to  20       „  2  cases. 

j>  j>  »>     ^O       J,         61     „ 


ETIOLOGY.  121 

The  disease  appeared  up  to  40  years  in  46  cases. 
})  >i         })        50       „         48     „ 

5>  jj  }}        oO       „  5     „ 

Above  60       „  0     „ 

Leubuscher^  has  reported  a  case  where  a  boy,  aged  three 
and  a  half,  was  affected,  and  no  neurotic  tendency  could 
be  traced  in  the  family  ;  Eulenburg,  one  in  a  girl  aged 
nine  ;  and  Bradbury,^  in  a  young  man  aged  nineteen.  On 
the  other  hand,  Trousseau  describes  the  case  of  a  patient  at 
^^g^^J  years  of  age,  where  the  muscular  force  appeared  to 
be  quite  intact.  It  is,  however,  not  quite  clear  that  this 
really  was  a  case  of  tabes. 

The  oldest  patient  with  unmistakeable  tabes  whom  I 
have  seen  was  a  gentleman  aged  seventy-two  (Case  31), 
who  consulted  me  in  June,  1881,  and  who  had  had 
syphilis  thirty  years  ago.  The  first  symptoms  of  tabes 
appeared  in  him  three  years  ago.  In  the  same  month,  I 
saw  another  gentleman,  aged  sixty-six,  a  widower  (Case 
32),  who  had  had  syphilis  twenty-six  years  ago.  He  had 
remained  well  for  sixteen  years,  and  it  was  only  then 
that  the  first  symptoms  of  tabes  presented  themselves. 
At  present  he  shows  all  the  usual  symptoms  of  the 
disease  confined  to  the  lower  dorsal  and  upper  lumbar  por- 
tion of  the  cord.     Such  cases,  however,  are  exceptional. 

With  regard  to  sex,  all  observers  are  agreed  that  the 
male  is  much  more  liable  to  tabes  than  the  female.  I  have 
never  seen  this  disease  in  a  lady,  but  a  good  many  cases 
of  it  amongst  the  out-patients  of  the  hospital.  These 
were  chiefly  women  who  had  to  work  in  damp  and  un- 
wholesome shops,  and  some  of  them  had  had  syphilis. 

Mobius  3  has  lately  described  five  cases  of  tabes  in 
women,  four  of  whom  had  syphilitic  husbands,  and  who  had 

'  "  Berliner  klinische  "Wochenschrift,"  1882,  No.  39. 

2  "British  Medical  Journal,"  1871,  No.  565. 

3  "  Centralblatt  fiir  Nervenheilkunde,'*  p.  193,  May  1,  1884. 


122  SCLEROSIS  OF  THE  SPINAL  CORD. 

had  frequent  miscarriages,  while  all  other  causes  of  the 
disease,  such  as  exposure  to  cold,  over-exertiou,  alcoholism, 
injury,  etc.,  were  wanting.  These  cases  are  particularly 
important,  because  in  men  there  are  generally  other  in- 
jurious influences  at  work,  as  for  instance  in  Cases  20  and 
21  (p.  105)  where  a  variety  of  causes  might  have  led  to  the 
outbreak  of  the  disease.  Singularly  enough,  there  were 
in  none  of  Mobius'  female  cases  any  of  the  ordinary  signs 
of  secondary  syphilis  ;  yet  their  history  leaves  no  doubt 
on  the  mind  that  in  these  tabes  was  really  of  a  specific 
character.  If  we  consider  how  difficult  it  frequently  is  to 
ascertain  the  existence  of  syphilis  in  women,  and  how 
eager  they  generally  are  to  deny  that  they  ever  had  such  a 
disease,  it  will  be  acknowledged  that  some  positive  evi- 
dence is  of  much  more  importance  than  numerous  negative 
statements.  Moreover  it  is  well  known  that  the  immediate 
consequences  of  infection  are  often  in  women  so  exceed- 
ingly obscure  that  they  are  themselves  unaware  of  being 
infected  ;  and  the  fact  that  in  men  often  just  the  appa- 
rently mild  forms  of  the  disease  appear  to  lead  to  tabes 
(p.  84),  no  doubt  also  applies  to  the  female  sex. 

Posterior  sclerosis  may  finally  be  a  secondary  disease, 
becoming  developed  consequently  upon  other  affections  of 
the  cord,  such  as  myelitis  from  compression,  Pott's  dis- 
ease, chronic  meningitis  or  meningo-myelitis,  secondary 
sclerosis  of  the  lateral  columns,  etc.  Such  cases,  however, 
do  not  offer  the  peculiar  type  of  the  primary  disease  ;  the 
symptoms  are  often  indistinct,  and  it  is  difficult  to 
make  an  accurate  diagnosis. 

***** 

The  causes  of  spastic  spinal  paralysis  are  analogous  to 
those  of  tabes  ;  yet  I  have  found  certain  differences  which 
appear  to  me  worthy  of  note.  Lathyrism,  corresponding 
to  ergotism,  has  already  been  mentioned  (p.  71).  But  in 
that  form  of  the  disease  which  occurs  habitually  in  prac- 


ETIOLOGY. 


123 


fcice,  some  points  have  struck  me  forcibly :  viz.,  first,  that 
the  influence  of  the  neurotic  constitution  is  much  more 
marked  in  the  production  of  this  disease  than  in  tabes  ; 
second,  that  the  occurrence  of  spastic  paralysis  is  appa- 
rently not  so  much  influenced  by  sex  and  age  as  tabes  ;  and 
third,  that  a  syphilitic  history  is  much  more  rarely  obtained 
in  this  affection  than  in  tabes. 

The  influence  of  the  neurotic  constitution  was  strongly 
marked  in  a  single  gentleman  (Case  33),  aged  sixty-two, 
who  first  consulted  me  in  January,  1878.  He  was  one 
one  of  twelve  children,  whose  truly  tragic  life-history  is 
as  follows  : — The  eldest  sister  died  of  consumption  at 
twenty-three  years  of  age  ;  the  eldest  brother  committed 
suicide  at  thirty-one.  The  next  sister  died  in  infancy  ; 
another,  who  is  her  twin- sister,  is  alive,  and  has  for  many 
years  past  suffered  from  an  intractable  form  of  epilepsy. 
The  next  is  the  patient  himself,  who  has  for  some  years 
past  been  subject  to  spastic  spinal  paralysis.  The  next 
brother  died  suddenly,  aged  twenty.  The  next  sister  is 
alive,  and  highly  nervous  ;  the  next  one  died  at  fifty,  from 
heart-disease.  After  that  come  two  twin-brothers,  another 
brother  and  a  sister,  all  of  whom  were  habitual  drunkards, 
and  died  of  the  effects  of  drink. 

In  another  patient  (Case  34),  a  young  lady,  aged 
twenty-two,  for  whom  I  was  consulted  in  May,  1878,  the 
parents  had  been  first  cousins  ;  the  mother  was  highly 
hysterical,  and  a  maternal  aunt  was  insane.  In  a 
number  of  other  patients  hysteria  of  the  mothers  was 
ascertained  ;  and  in  most  of  these  cases  no  particular 
exciting  cause  of  the  outbreak  of  the  disease  could  be 
elicited. 

As  far  as  sex  is  concerned,  the  female  seems  to  be  quite 
as  liable  to  it  as  the  male,  as  amongst  forty-nine  cases 
of  which  I  have  notes,  I  found  twenty-four  males  and 
twenty-five  females.  The  ages  at  which  the  disease  first 
appeared  were  as  follows  : — 


124 


SCLEROSIS  OF  THE  SPINAL  CORD. 


Up  to           10 

years... 

...     5 

cases 

From  11  ^to  20 

...     8 

„     21  'to  30 

...     9 

„     31  to  40 

...     8 

„     41  to  50 

...   10 

„     51  to  60 

...     8 

After            60 

...     1 

49 

If  this  list  is  compared  with  the  one  of  the  ages  at 
which  tabes  has  appeared  (p.  120),  a  considerable  differ- 
ence will  be  noticed. 

Syphilis  has  already  been  mentioned  (p.  53)  as  having 
evidently  caused  the  affection  in  Minkowski's  case  ;  and 
Westphal  has  published  a  similar  one.  The  following  are 
a  few  cases  taken  from  my  own  note-book  : — 

Case  35. — A  sailor,  aged  twenty-eight,  married,  and 
father  of  two  children,  was  admitted  into  the  hospital  under 
my  care  in  April,  1882.  He  had  had  small-pox  when 
eight  years  of  age,  and  had  contracted  syphilis  four  years 
ago  ;  but  he  attributes  his  present  affection  to  having  got 
wet  at  sea.  Three  months  ago  he  felt  that  he  was  gradu- 
ally losing  the  power  over  both  arms  and  legs  ;  and  he  is 
now  so  feeble  that  he  cannot  walk  at  all.  There  is  great 
exaggeration  of  the  deep  reflexes  in  all  four  extremities  ; 
no  wasting  nor  unusual  electrical  reactions  ;  there  is  in- 
continence of  the  urine,  and  habitual  constipation  ;  and 
there  never  has  been  any  pain  or  other  affection  of  sensi- 
bility. 

Case  36. — A  surgeon,  who  had  lived  a  good  deal  in  the 
East  and  on  board  ship,  consulted  me  in  September, 
1881.  He  had  had  syphilis  first  in  1861,  and  then 
again  very  badly  in  1865.  In  1866  he  was  taken  ill 
at  Calcutta  with  fever,  but  nevertheless  went  off  in  a  ship, 
taking  charge  of  coolies  .for  Trinidad.  He  afterwards  came 
to  England,  and  was  laid  up  with  jaundice  ;  he  had  reten- 


ETIOLOGY.  125 

tion  of  the  urine  and  convulsions  in  the  left  leg,  and 
became  so  feeble  that  he  was  weeks  before  he  could  crawl 
from  his  bed  to  the  sofa  on  all  fours.  He  now  presented 
spastic  gait,  great  increase  of  all  the  tendon  reflexes,  and 
no  affection  of  sensibility. 

Case  37. — In  July,  1883,  I  was  consulted  by  an  Ameri- 
can gentleman,  aged  forty-five,  single,  who  had  mastur- 
bated as  a  boy,  and  had  syphilis  twenty  years  ago.  For 
some  years  past  he  had  felt  his  sexual  desire  and  power 
gradually  lessening  ;  and  at  present  there  was  total  ana- 
phrodisia  and  impotency.  In  addition  to  this,  the  patient 
suffered  from  constipation  and  frequent  attacks  of  "  con- 
gestion of  the  liver."  He  also  complained  of  general 
debility  and  not  being  able  to  walk  well.  The  gait 
was  that  of  incipient  lateral  sclerosis  ;  and  the  deep 
reflexes  were  considerably  exaggerated  in  all  four  ex- 
tremities. 

A  not  infrequent  cause  of  this  form  of  sclerosis  appears 
to  be  external  injury.  A  fall  from  a  horse  was  mentioned 
to  me  as  the  only  possible  cause  of  his  illness  by  a  mer- 
chant, a  native  of  Barbadoes,  aged  fifty  (Case  38),  married 
and  childless,  who  consulted  me  in  June,  1883,  and  who 
had  for  about  twelve  months  past,  suffered  from  gradually 
increasing  debility  in  walking  (spastic  gait),  and  had  be- 
come much  emaciated  in  his  lower  extremities.  His  arms 
and  hands  were  likewise  much  weaker  than  they  had 
been  before.  The  tendon  reflexes  in  all  four  extremities 
were  greatly  exaggerated,  with  spinal  type.  There  was 
no  affection  of  sensibility,  and  the  bladder,  bowels,  and 
sexual  organs  appeared  to  be  in  their  normal  condition. 

A  similar  case  was  that  of  a  single  lady,  aged  sixty-three 
(Case  39),  who  consulted  me  in  January,  1882.  Ten  years 
ago,  when  visiting  a  picture  gallery  in  Rome,  she  accident- 
ally put  her  foot  into  a  hole  in  the  floor  and  fell,  severely 
jarring  her  spine.  Ever  since  then  she  has  not  been  able 
to  walk  well,  and  has  constantly,  although  very  gradually. 


126  SCLEROSIS  OF  THE  SPINAL  CORD. 

got  worse.  On  examining  the  legs,  the  muscles  appeared 
well  nourished,  and  responded  readily  to  faradisation. 
There  was  no  anaesthesia,  but  great  exaggeration  of  all 
the  deep  reflexes.  The  patient  could  only  walk  with  sup- 
port on  both  sides,  and  showed  the  characteristic  gait  of 
spastic  paralysis. 

Another  single  lady,  aged  fifty-one  (Case  40),  con-^ 
suited  me  in  the  same  week.  She  had  always  been 
in  good  health  until  eight  years  ago,  when  the  horses 
of  the  carriage  in  which  she  was  driving  took  fright 
and  upset  it.  She  was  thrown  out,  and  hurt  the 
lumbar  portion  of  the  spine.  There  was  no  fracture  or 
dislocation,  but  bruises  and  severe  pain  ;  and  the 
patient  has  never  been  able  to  walk  properly  since. 
There  is  now  extreme  exaggeration  of  all  the  tendon  re- 
flexes in  both  lower  extremities,  and  all  the  other  symp- 
toms of  spastic  paraplegia.  More  recently  the  right  arm 
has  also  become  very  weak.  With  the  right  hand  she 
squeezes  the  dynamometer  only  to  40°,  while  with  the  left 
she  has  a  grasp  of  100°.  She  complains  of  pain  in  the 
right  arm,  about  the  region  of  the  insertion  of  the  deltoid 
muscle.  She  has  difficulty  in  lifting  the  right  arm,  is 
unable  to  do  her  hair,  or  to  dress  herself  without  assistance. 
The  tendon  reflexes  of  the  right  arm  and  hand  are  exag- 
gerated, and  present  a  striking  contrast  to  the  left  upper 
limb,  where  there  is  no  such  exaggeration.  Otherwise  she 
is  in  good  health.  Her  catamenia  left  her  without  any 
trouble  twelve  months  ago  ;  and  she  has  no  difficulty  witk 
the  bladder  and  rectum. 

Spastic  paralysis  sometimes  appears  after  acute  diseases  : 
I  have  seen  it  after  scarlet  fever  and  typhoid  fever.  One 
of  my  patients,  a  lady,  aged  thirty,  attributed  her  malady 
to  over-exertion  in  nursing  a  brother  day  and  night  through 
a  tedious  illness  which  required  constant  attendance,  and 
more  especially  incessant  lifting  and  shifting  of  position. 
In  the  case  of  a  clerk,  aged  thirty  (Case  41),  the  symptoms 


ETIOLOGY.  127 

came  on  after  violent  catheterisation.  This  patient  had  had 
gonorrhoea,  which  left  a  stricture,  and  was  subject  to 
occasional  attacks  of  retention  of  urine.  In  one  of  these 
attacks  a  false  passage  was  made  with  the  instrument, 
after  which  severe  symptoms  of  urethritis  and  cystitis  be- 
came developed.  When  the  patient  recovered  from  this, 
he  found  that  he  had  difficulty  in  walking  ;  and  when  I 
examined  him  in  February,  1883,  the  symptoms  of  spastic 
paralysis  were  well  marked. 

The  causes  of  insular  sclerosis  are  as  yet  not  well  known. 
In  a  case  of  this  kind,  which  I  saw  with  Dr.  Philpot,  of 
Croydon,  in  October,  1882,  the  patient,  an  auctioneer, 
aged  forty-one  (Case  42),  had  been  twice  married,  had  had 
a  chancre  and  a  bubo  at  eighteen  years  of  age,  but  appa- 
rently no  secondary  symptoms.  He  confessed  to  consider- 
able sexual  excesses.  About  three  and  a  half  years  ago 
he  began  to  find  his  speech  becoming  affected  ;  articula- 
tion was  drawling  and  indistinct.  This  had  got  much 
worse  lately,  but  the  patient  had  full  command  over  his 
words  ;  and  the  tongue  was  neither  tremulous  nor  wasted. 
The  head  was  bent  forward  on  the  chest,  from  paresis  of 
the  trapezius  and  other  muscles  of  the  neck  ;  but  with  an 
effort  the  patient  was  able  to  throw  the  head  backwards, 
and  also  to  move  it  from  one  side  to  the  other,  without 
much  tremor.  There  was,  however,  well  marked 
sclerotic  tremor  in  the  left  side  of  the  body  on  moving 
the  limbs,  but  only  very  slightly  so  during  rest.  He 
squeezed  the  dynamometer  with  the  right  hand  to  1 60°, 
and  with  the  left  to  120°  ;  and  although  there  was,  there- 
fore, a  very  good  degree  of  muscular  force,  yet  this 
appeared  to  be  of  very  little  use  to  the  patient.  It  is 
true  that  he  could  write,  but  very  slowly  and  awkwardly. 
He  could  button  his  trousers,  but  with  great  difficulty  ;  he 
was  unable  to  cut  his  meat,  and  had  to  feed  himself  with  a 
spoon.  The  sclerotic  tremor  of  the  left  arm  was  much 
increased  when  he  attempted  to   speak.     The  backward 


128  SCLEROSIS  OF  THE  SPINAL  CORD. 

motion  of  both  hands,  as  when  he  wanted  to  use  the  hair- 
brush, was  very  much  interfered  with.  The  spine  felt 
lumpy,  clogged,  and  weak.  He  had  often  shooting  pains 
through  the  back,  with  shivering.  He  could  not  sit 
straight  in  a  chair,  and  preferred  lying  to  sitting,  and 
running  to  walking.  He  could  still  walk  about  three 
miles  a  day,  but  perspired  profusely  after  having  walked 
for  about  a  mile.  All  the  deep  reflexes  were  exag- 
gerated ;  but  there  was  no  affection  of  sensibility,  and 
no  symptoms  of  syphilis  in  the  skin,  mucous  membranes, 
and  bones. 

The  neurotic  constitution  was  very  obvious  in  a 
married  lady,  aged  thirty-five,  and  mother  of  two  children 
(Case  43),  whom  Mr.  Maclaren  requested  me  to  see,  in 
April,  1883.  She  had  for  five  years  past  suffered  from  a 
gradually  increasing  loss  of  power  in  the  lower  extremities. 
Her  father  and  mother  had  died  of  apoplexy^  and  a  sister  had 
suffered  from  infantile  paralysis.  The  disease  commenced 
without  any  appreciable  cause,  and  the  patient  had, 
throughout  all  these  years,  never  had  an  ache  or  pain.  She 
was  now  confined  to  her  couch,  but  could  sit  up  on  a  com- 
fortable chair  for  some  time.  The  legs  were  utterly 
useless,  and  almost  entirely  paralysed ;  she  could,  how- 
ever, push  the  left  leg  down  when  it  was  drawn  up.  Both 
legs  were  much  emaciated,  and  the  faradic  excitability  of 
the  nerves  and  muscles  was  diminished,  while  the  voltaic 
response  appeared  normal.  The  knee-jerk  was  much 
increased  in  both  sides,  but  there  was  no  ankle-clonus. 
Sensibility  was  perfectly  normal.  The  upper  extremities 
were  likewise  very  useless  and  wasted.  She  could  not 
wash  her  hands,  write,  dress,  or  feed  herself.  The  dyna- 
mometer showed  25)°  with  the  right,  and  30°  with  the 
left  hand.  There  was  nystagmus  and  a  slight  degree  of 
excavation  of  the  optic  nerves,  without,  however,  any  cor- 
responding loss  of  sight. 

Insular  sclerosis  is   not  uncommon  in  children,  and  has 


ETIOLOGY. 


129 


been  observed  at  so  early  an  age  as  fourteen  months,  but 
is  more  common  in  them  between  three  and  four  years  of 
age.  In  children  a  blow  or  a  fall  is  often  supposed  to  be 
the  cause,  although  no  very  definite  relationship  has  as  yet 
been  estabhshed  between  accidents  and  insular  sclerosis. 
On  the  other  hand,  it  is  certain  that  the  disease  is  apt  to 
appear  after  scarlet  fever,  jaundice,  typhoid  fever,  cholera, 
and  small-pox.  Whether  these  morbid  poisons  have  a 
tendency  to  invade  directly  certain  portions  of  the  nervous 
system,  or  whether  the  latter  is  affected  secondarily,  in 
consequence  of  certain  systemic  changes  brought  about  by 
the  action  of  these  poisons,  is  as  yet  unsettled.  Insular 
sclerosis  has  also  been  observed  in  gouty  subjects  ;  and  it 
appears  to  be  occasionally  hereditary. 

Only  Httle  is  known  at  present  about  the  causes  of 
amyotrophic  lateral  sclerosis.  It  generally  occurs  in  persons 
between  thirty  and  fifty  years  of  age  ;  but  Seeligmiiller  has 
seen  four  children  of  a  family  affected  with  it,  whose  ages 
were  between  one  and  eleven  years.  Syphilis  and  ex- 
posure to  cold  have  appeared  to  me  the  most  probable 
causes  of  this  variety  of  sclerosis. 


K 


130  SCLEROSIS  OP  THE  SPINAL  COED. 


CHAPTER  VI. 

SYMPTOMS  OF  TABES  SPINALIS. 

That  the  course  of  tabes  spinalis  shows  several  distinct 
stages  was  first  recognised  by  Duchenne,^  who  divided  the 
disease  into  three  different  periods.  The  first  was,  accord- 
ing to  him,  characterised  by  the  occurrence  of  palsies  of 
one  or  several  of  the  motor  nerves  of  the  eye,  or  their 
branches,  of  amblyopia  and  amaurosis,  and  of  lightning- 
pains  ;  the  second,  by  symptoms  of  motor  incoordination  • 
in  the  lower  and  sometimes  in  the  upper  extremities,  to 
which,  soon  afterwards  or  at  once,  were  added  anaesthesia 
of  the  muscles,  joints,  bones,  and  the  skin ;  while  in 
the  third  period  the  malady  became  generalised.  These 
three  stages  have  subsequently  been  called  (1)  the  pre- 
monitory, prodromial,  or  pre-ataxic  stage,  (2)  the  ataxic, 
and  (3)  the  paralytic  or  terminal  stage  ;  and  they  are 
sufficiently  well  marked  in  a  large  number  of  cases  to 
warrant  us  in  adhering  to  this  division.  In  other  cases 
only  two  stages  can  be  distinguished,  viz.,  a  pre-ataxic  and 
an  ataxic  one,  as  the  patients  do  not  live  long  enough  to 
reach  the  third  or  paralytic  stage.  The  first  stage  should 
not  be  called  "  premonitory "  or  "  prodromial,"  because 
the  peculiar  lesion  of  tabes  is  already  established  in  the 
beginning  of  the  malady,  which  latter  is  at  no  period 
functional  in  character.  The  pathological  difference  between 
the  several  stages  is  therefore  only  one  of  degree,  inasmuch 
as  in  the  first  stage  a  small  number,  in  the  second  a  much 

^  "Archives  Generales  de  Medecine,"  December,  1858;  Jan.,  Feb., 
and  March,  1859. 


SYMPTOMS  OF  TABES  SPINALIS.  131 

larger  number,  and  in  the  last  the  totality  of  the  nerve- 
tubes  of  the  posterior  columns  are  diseased  or  destroyed. 

From  this  it  naturally  follows  that  no  hard  and  fast  line 
can  be  drawn  between  the  several  periods  of  tabes  ;  and 
this  view,  which  is  suggested  by  the  pathological  anatomy 
of  the  complaint,  is  fully  corroborated  by  the  clinical 
symptoms.  It  is,  therefore,  in  many  cases  impossible  to 
say  whether  a  patient  is  in  the  first  or  second,  or  in  the 
second  or  ^lird  stage  of  the  disease.  The  ataxy  of  move- 
ment, as  well  as  of  standing,  is  often  so  slight  that  it  can 
only  be  discovered  by  careful  examination  ;  and  it  would 
be  inexpedient  to  say  that  a  patient,  who  may  still  be  able 
to  walk  eight  or  ten  miles  at  a  stretch  without  any  diffi- 
culty, is  in  the  second  stage  of  locomotor  ataxy.  On  the 
other  hand,  the  ataxy  of  gait  may  be  so  severe  that, 
although  the  patient  may  still  be  able  to  move  his  limbs, 
he  is  more  helpless  than  another  patient  who  may  have 
been  actually  paralysed  through  a  stroke  of  cerebral 
haemorrhage.  The  stages  or  periods  of  the  disease  should, 
therefore,  be  looked  upon  as  only  approximatively  true  to 
nature. 

The  clinical  signs  of  tabes  have  gradually  become  more 
and  more  numerous  as  greater  attention  has  been  directed 
to  this  disease  ;  and  the  descriptions  given  by  Romberg 
and  Duchenne,  excellent  as  they  are,  will  now  be  found  to 
contain  only  a  fraction  of  the  symptoms  which  are  now 
habitually  observed  in  patients  of  this  kind.  In  order 
therefore,  to  render  this  part  of  my  subject  as  clear  as 
possible,  I  shall  begin  with  and  lay  chief  stress  upon  the 
most  important  symptoms,  and  those  which  are  of  the 
greatest  value  in  enabling  us  to  make  an  early  diagnosis 
of  the  disease.     These  are — 

1.  Loss  of  the  knee-jerk  (Westphal's  symptom) ; 

2.  Lightning  pains ; 

3.  Reflectory  rigidity  of  the  pupil  (Argyll-Robertson's 
symptom). 

k2 


132  SCLEROSIS  OF  THE  SPINAL  CORD. 

If  these  three  symptoms  are  found  together,  the  diag- 
nosis of  tabes  may  be  considered  certain. 

1.  Loss  of  the  Tcnee-jerh. — This  symptom,  which  was 
discovered  by  Westphal  in  1875,  is,  without  exception, 
diagnostically  the  most  important  one  in  the  earliest  stages 
of.  tabes.  In  health,  a  more  or  less  smart  tap  on  the 
patellar  tendon  with  a  finger  or  the  ulnar  side  of  the 
hand,  the  ear-piece  of  a  stethoscope,  or,  better  still,  with 
a  percussion  hammer,  causes  the  leg  to  be  jert^d  forward 
more  or  less  freely.  The  phenomenon  may  be  obtained 
when  the  patient  is  sitting  on  a  chair,  and  crosses  one 
leg  over  the  other  ;  but  where  the  legs  are  short  and  stout, 
it  is  better  to  let  him  sit  on  the  edge  of  a  table,  with  his 
legs  hanging  down.  Where  the  patient  is  examined  in  bed, 
the  limb  should  be  raised  by  the  observer  passing  his  left 
hand  underneath  the  thigh,  just  above  the  knee,  and 
giving  the  tap  with  the  right  hand.  In  general,  it  is  not 
necessary  for  the  patient  to  be  undressed  ;  but  where  the 
result  is  doubtful,  it  is  always  best  to  strike  the  bare  skin 
over  the  tendon  ;  and  it  may  be  useful,  more  especially 
where  the  patient  appears  nervous  and  excitable,  to  have 
his  eyes  bandaged,  so  that  any  interference  on  his  part 
with  the  production  of  the  phenomenon  may  be  prevented. 

The  controversy  about  the  exact  nature  of  the  pheno- 
menon, which  commenced  soon  after  its  discovery,  is  still 
progressing,  and  likely  to  continue  for  some  time  to  come. 
The  highly  complex  character  of  an  apparently  simple 
sign  affords  considerable  opportunities  for  the  exercise  of 
physiological  ingenuity  ;  and  it  is  satisfactory  to  find  that 
experimental  physiologists,  who  owe  the  knowledge  of  this 
physiological  sign  to  a  doctor,  should  have  taken  up  the 
study  of  it  with  so  much  zeal,  although,  perhaps,  some- 
what late  in  the  day,  considering  that  it  is  within  their 
own  special  province. 

Westphal  and  others  consider  the  knee-jerk  to  be  owing 
to    a  direct  stimulation  of  the  muscular  substance,  while 


SYMPTOMS  OF  TABES  SPINALIS.  133 

Erb  and  others    maintain   that   it  is    produced  by  reflex 
action.     There  is  a  considerable  amount  of  evidence  in 
favour  of  either  theory,  into  which  this  is  not  the  place 
fully  to  enter.   Suffice  it  to  say  that,  according  to  Westphal, 
the  essential  conditions  for  the  production  of  the  knee-jerk 
are,  that  there  should  be  a  proper  muscular  tone,  a  certain 
degree  of  tension  of  the  muscle,  and  the  possibility  of  the 
tendon  vibrating  ;  and  that  there  is  no  need  for  assuming 
reflex  action  by  centripetal  nerves  of  tendons  and  muscles, 
but  that  the  contraction  of  the  muscle  is  caused  by  the 
specific  stimulus  of  the  vibrating  tendon.      Erb,  on   the 
other   hand,  has  pointed  to  the    discovery    of  nerves  in 
tendons,  which  was  made  by  Sachs^  about  the  same  time 
that  the  knee-jerk  first  attracted  attention.     These  nerves 
are  situated  at  the  point  where  the  muscle  and  tendon 
touch  one  another  ;  they  are  excited  when  the  tendon  is 
struck,   and  conduct  the  stimulation  to  the   spinal  cord, 
the  tendon  being  an  elastic  medium  which   only  wants  a 
certain  degree  of  tension  for  transmitting  the  concussion. 
In  order  that  the  knee-jerk  should  be  producedit  is  neces- 
sary that  the  reflex  path  between  the  tendon,  the  spinal 
cord,  and  the  rectus  femoris  should  be  in  a  state  of  integrity; 
and  where  this   is  interrupted,  as  in  tabes,  by  disease  of 
the'  posterior  roots  and  columns,  in  infantile  paralysis  by 
disease  of  the  anterior  grey  matter,  and  in  neuritis  by  dis- 
ease of  the  peripheral  nerves,  the  knee-jerk  is  found  to  be 
absent.    In  spite  of  a  considerable  number  of  physiological 
researches  undertaken    by  such  observers  as   Tschirjew, 
Gowers,  Berger,  Brissaud,  Eulenburg,  and  many  others, 
with   the  view  to  arrive    at   a  definite  conclusion,    both 
Westphal  and  Erb  have  until  now  adhered  to  the  position 
originally  taken  up  by  them  ;  yet   signs  are  not  wanting 
that  the  reflex,  theory  is   destined  eventually  to  gain  the 
day.     The    principal  argument  of  the  opponents   of   the 

1  Keichert'B  and  Du  Bois-Eeymond's  "  Archiv."    Berlin,  1875. 


134  SCLEROSIS  OP  THE  SPINAL  CORD. 

reflex  theory  is,  that  the  time  in  which  the  knee-jerk  is 
produced  is   too   short  for   a  true  reflectory  process,  inas- 
much as  the  period  required  for  a  stimulus  to  travel  from 
the  patellar  tendon  to  the  cord,  and  from  the  cord  back 
again  to  the  quadriceps   femoris,  would  amount    at  least 
to  one-fifteenth  part  of  a  second;  while  as    a  matter  of 
fact  much  less  time  intervenes  between  the  two  actions? 
viz.,    from   the    twenty-fifth    to    the    thirtieth  part  of    a 
second.    This  view,  to    which  more  especially    Gowers^ 
attaches    considerable    importance,    is,  however,    contro- 
verted by  Rosenheim,^  who  has  made  the  latest  experi- 
ments on  this   subject  in  the  physiological  laboratory  of 
the  University  of  Berlin,  and  who  has  found  that  in  men, 
as  well  as  in  rabbits,  the  least  duration  of   latency  is  0'02o 
of  a  second,  but  that  it  is  often  much  more,  and  that  this  is 
quite  compatible  with  the  reflex  nature  of  the  phenomenon. 
He  objects  to  the   mode   of  experimentation  adopted  by 
Gowers  and  Eulenburg  as  containing  sources  of  error,  and 
has  adopted  an  entirely  different  mode  of  research,  which 
has  led  to  different  results.     He  finds  that  the  portion  of 
tendon  which  is   struck   is   of  importance,   and  that  the 
transmission  of  the  stimulus  to  the  muscle  is  not  exactly 
the   same  from  all  parts.     The  duration  of  latency  is  in- 
versely proportional  to  the  force  of  percussion,  in  normal 
as  well  as  pathological  conditions.  The  latency  is  increased 
in   proportion  to  the  number  of  taps  ;    so  that  the  excita- 
bility of  the  percussed  part  is  diminished  by  the  duration 
of  the  experiment.     The  latency  does  not  differ  much  in 
pathological  conditions.    Rosenheim  also  found  that  while 
the    opening  and   closing  shock  of    the    electro-magnetic 
current  was  unable  to  produce  the  knee-jerk,  this  could  be 
elicited  by  the  application  of  the  magneto-electric  current 
to  the  patellar  tendon,  and  also  by  reversing  the  direction 

^  "The  Diagnosis  of  Diseases  of  the  Spinal  Cord,"  p.  25.    Third 
edition.     London,  1884. 

2  "  ArcMv  fiir  Psychiatric,"  vol.  xv.,  p.  180.     1884. 


SYMPTOMS  OF  TABES  SPINALIS.  135 

of  a  powerful  continuous  current  applied  to  the  same 
(voltaic  alternatives).  The  phenomena  observed  by  him 
have  led  him  to  the  conclusion  that  no  data  exist  which 
speak  against  the  knee-jerk  being  due  to  reflex  action. 

It  appears  to  me  that  an  examination  of  the  knee-jerk 
in  cases  of  fracture  of  the  patella  might  contribute  much 
to  the  solution  of  this  question.  I  lately  examined  two 
cases  of  this  kind  where  partial  union  had  taken  place, 
and  which  were  exhibited  by  Mr.  Christopher  Heath  and 
Mr.  Morris  at  a  meeting  of  the  Clinical  Society  of  London, 
and  found  the  knee-jerk  equally  strong  in  the  limb  where 
the  patella  had  been  fractured  as  in  the  healthy  one.  It 
would,  however,  be  chiefly  in  fresh  cases  of  fracture  of 
the  patella,  where  there  is  a  considerable  interval  be- 
tween the  broken  fragments,  that  such  an  examination 
might  lead  to  useful  results.  It  stands  to  reason  that  per- 
cussion of  the  ligamentum  patellae  could  not  have  the  same 
effect  in  eliciting  the  knee-jerk  in  a  case  of  fracture,  if 
the  phenomenon  was  owing  to  direct  stimulation  of  the 
muscular  substance,  as  the  tension  of  the  quadriceps  and 
the  vibratory  power  of  the  tendon  must  be  considerably 
altered  under  such  circumstances  ;  while  if  the  knee-jerk 
were  due  to  reflex  action,  little  or  no  change  would  pro- 
bably be  observed.  Hospital  surgeons,  who  have  the  oppor- 
tunity of  seeing  such  cases  immediately  after  the  accident 
has  occurred,  should  utilise  those  occasions  by  observing 
the  behaviour  of  the  knee-jerk  where  the  fragments  of 
the  patella  are  widely  apart,  and  thus  contribute  to  the 
settlement  of  an  interesting  physiological  question.  The 
observations  made  by  myself,  in  the  two  cases  just  alluded 
to,  incline  me  even  more  than  before  to  lean  to  the  reflex 
theory  of  the  phenomenon. 

The  reflex  centre  for  the  knee-jerk  is  situated  in  the 
lumbar  portion  of  the  spinal  cord,  in  the  region  correspond- 
ing to  the  second,  third,  and  fourth  lumbar  nerves ;  and  the 
"  reflex  arc  "  comprises,  on  the  one  hand,  the  afferent  nerves 


136  SCLEROSIS  OF  THE  SPINAL  CORD. 

from  the  patellar  tendon,  the  posterior  nerve-roots,  and  the 
posterior  grey  horns  ;  and,  on  the  other  hand,  the  anterior 
grey  horns,  the  anterior  nerve-roots,  and  the  efferent  nerves 
proceeding  to  the  quadriceps  muscle.     Any  interruption  of 
the  integrity  of  this  reflex-arc  may  cause  loss  of  the  knee- 
jerk  ;  and  before  arriving,  simply  from  the  absence  of  this 
phenomenon,   at    a    diagnosis  of  tabes,  we  must  exclude 
infantile     paralysis,    pseudo-hypertrophic     paralysis,    and 
muscular  atrophy  owing  to  neuritis,  such  as  diphtheritic 
paralysis,  etc.     For  this  it  is  necessary  to  call  in  the  aid 
of  electricity  and  mechanical  stimulation  of  the  muscular 
fibres.     If  there  is  normal  response  to  faradisation,  and  if 
the  quadriceps  femoris  responds  by  contraction  to  a  tap  with 
the  percussion  hammer  directly  applied  to  its  substance, 
the   diseases  just  mentioned  may   be  excluded.      It  is  a 
singular   fact   that   in   tabes   with   loss    of  knee-jerk  the 
mechanical  irritability  of  the  quadriceps,  more  especially  of 
that  portion  of  it  which  is  called  the  vastus  internus,  is 
often  increased  (Erb,  Buzzard),  which  adds  to  the  value  of 
the  symptom.      This  increase  of  muscular  excitability  is 
probably   owing  to  irritation  of  the  posterior  root-fibres,, 
while  the  loss  of  the  knee-jerk  must  be  owing  to  destruc- 
tion of  some    essential   portions  of  the  same.      In  order 
therefore  to  be  pathognomonic,  the  loss  of  the  knee-jerk 
must  be  combined  with  good  voluntary  power,  a  proper 
faradic    response,    and    idio-muscular   contraction   of    the 
vastus  internus. 

The  physiological  and  diagnostic  importance  of  the 
knee-jerk,  and  the  modifications  which  it  undergoes  in 
certain  cerebral  and  spinal  diseases,  has  been  almost 
universally  acknowledged  immediately  after  Westphal 
had  brought  his  researches  on  this  subject  before  the 
profession  ;  and  it  is  not  too  much  to  say  that  we  owe 
to  this  distinguished  physician  and  teacher  a  debt  of 
gratitude  for  the  new  light  which  the  study  of  these 
phenomena    has    thrown     upon    many    obscure    diseases 


SYMPTOMS  OF  TABES  SPINALIS.  137 

of  the  nervous  system.  The  assistance  which  we  derive 
day  by  day  in  onr  diagnosis  of  obscure  cases  of  ner- 
vous affections,  by  utilising  these  phenomena,  is  incal- 
culable ;  and  information  thus  obtained  is  often  of  the 
greatest  value.  It  seems  therefore  singular  that  even  now 
this  symptom  is  very  little  thought  of  in  France.  Vulpian, 
in  his  otherwise  very  able  lectures  on  tabes,  makes  a  sneer- 
ing remark  about  the  discovery  "  which  Westphal  thinks  he 
has  made  ;  "  while  Fournier^  laments  the  uncertainty  of 
diagnosis  in  the  earliest  stages  of  tabes,  when  such  a 
symptom  is  within  his  reach  !  The  latter  author  says : — 
"II  est  des  malades  qui,  pendant  plusieurs  annees — trois^ 
cinq,  six,  meme  buit  et  dix  annees — ne  presentent  rien 
autre  comme  phenomenes  morbides  que  des  acces  plus 
ou  moins  espaces  des  douleurs  fulgurantes ;  .  .  ."  and 
further  on  (p.  55)  : — alors  meme  que  les  malades,  s'in- 
quietant  de  ces  douleurs,  viendraient  a  nous  des  leur  ap- 
parition premiere,  il  y  aurait  encore  toutes  chances  pour 
qu'elles  restassent  meconnues  quant  a  leur  nature  reelle,. 
quant  a  leur  valeur  semeiologique  .  .  .  Mai  decrites  sans 
doute  par  le  patient,  vagues  de  siege,  indecises  comme 
caractere,  ces  douleurs  ont  ete  prises  pour  ce  qu'elles 
n'etaient  pas,  et  rapportees  tantot  a  de  simples  nevral- 
gies,  tantot  a  des  rhumatismes,  tantot  a  ceci  ou  cela,  mais 
jamais  au  tabesJ' 

Loss  of  the  knee-jerk  is  found  in  all  cases  of  uncom- 
plicated tabes  where  we  have  to  do  with  sclerosis  of  the 
posterior  columns  in  the  lumbar  portion  of  the  cord  ;  and 
this  symptom  is  of  the  greatest  diagnostic  value,  more 
especially  in  those  by  no  means  unfrequent  cases  where 
the  other  symptoms  of  spinal  disease  are  somewhat  indis- 
tinct, and  it  may  be  overshadowed  by  signs  which  are  apt  to 
be  referred  to  stomach  and  liver  derangement,  or  are  believed 
to  be  owing  to  gout,  hypochondriasis,  and  other  diseases. 

There  is  reason  to  believe  that  loss  of  the  knee-jerk  is 

'  **  De  I'ataxie  locomotrice  d'origine  syphHitique,"  p.  50.    Paris,  1882. 


138  SCLEROSIS  OF  THE  SPINAL  CORD. 

in  some  cases  the  first,  and  in  the  majority  of  cases  one  of 
the  first  symptoms  of  tabes.  It  was  found  to  have  disap- 
peared at  a  very  early  stage  of  the  disease  in  the  epidemic 
of  ergotism  which  has  been  described  by  Tuczek,  and  was 
in  one  case  the  first  and  only  symptom  of  posterior  sclerosis. 
There  is  some  reason  to  believe  that  loss  of  the  knee-jerk 
may  occasionally  be  preceded  by  paralysis  of  the  rectus 
externus  or  of  some  other  muscle  of  the  eye  ;  but  definite 
data  about  this  are  as  yet  wanting. 

The  following  case  is  of  interest  in  connexion  with  this 
point,  although  the  precise  date  of  the  loss  of  the  knee- 
jerk  could  not  be  ascertained  : — 

Case  44. — A    country    doctor,   aged   72,   married,    who 
had   had  thirteen  children  and  forty-nine  grandchildren, 
and  had  been  very  successful   in   practice,  consulted  me 
in   February,   1882.      He  had   always  enjoyed   excellent 
health,   and   had    only   quite    recently   retired   from    the 
active    duties    of    the    profession.      He   complained  that 
for  some  time  past  he  had,  on  awakening  in  the  morn- 
ing, been  greatly  troubled  by   tingling  and  numbness  in 
both  hands,  and  more  particularly  the  right.     The  numb- 
ness   could   be   relieved  by  rubbing,    and  did  not  return 
again  during  the   day,   but  was   always  present  the  first 
thing  in  the  morning.      On  examining  the  patient  I  found 
complete  absence  of  the  knee-jerk    in    both  sides,   with 
direct  response  of  the  vastus  internus.     He  denied  having 
ever  had  syphilis,   but    informed    me,    in    answer   to   my 
inquiry,  that  he  had  had  double  vision  eight  years  ago, 
for  which  he  had  been  treated  by   Sir  William  Bowman. 
This  disappeared  in  about  a  month,  and  had  never  returned. 
There  was  no  history  of  any  other  symptoms  of  tabes,  nor 
could  the  closest  examination  reveal  the  presence  of  any 
of  them.     The   diagnosis  might  therefore  in  this  case  be 
considered   somewhat    doubtful;    yet   the    coincidence    of 
double  vision,  loss  of  knee-jerk,  and  numbness  is,  to  say 
the  least,  peculiar,  and  may  at  some  future  time  be  followed 


SYMPTOMS  OF  TABES  SPINALIS.  139 

by  other  symptoms  of  that  disease.  The  patient's  age 
might  seem  to  speak  somewhat  against  the  supposition  of 
tabes,  but  we  have  seen  in  the  preceding  chapter  (p.  121) 
that  an  advanced  age  is  by  no  means  incompatible  with 
the  evolution  of  the  disease. 

I  have  never  found  the  knee-jerk  absent  in  healthy 
persons,  excepting  in  the  two  extremes  of  life.  It  is 
difficult  or  impossible  to  elicit  it  in  some  children  before 
they  have  learnt  to  walk,  and  also  in  decrepit  old  persons 
where  there  appears  to  be  no  particular  form  of  spinal 
disease  (Mobius).  The  subject  of  Case  44,  however,  could 
not,  although  of  an  advanced  age,  be  considered  in  the 
least  decrepit,  as  his  physical  health  and  his  mental  energy 
appeared  to  be  very  good. 

In  the  following  case  the  diagnosis  of  gout  had  been 
made  by  several  experienced  practitioners  ;  and  it  was 
chiefly  the  absence  of  the  knee-jerk  which  enabled  me  to 
recognise  the  existence  of  tabes. 

Case  45. — A  stockbroker,  aged  59,  married,  but  childless, 
consulted  me  in  October,  1881.  He  complained  of  "  being 
eaten  up  with  the  gout,"  and  having  the  most  fearful  gouty 
pains  in  his  head,  chest,  back,  loins,  thigh,  stomach,  and, 
worst  of  all,  in  the  bladder.  He  had  had  syphilis  fifteen 
years  ago,  but  had  never  shown  any  symptoms  of  it  during 
the  last  twelve  years.  He  had  lately  been  treated  with 
citrate  of  potash,  lithia,  and  colchicum,  but  without  relief. 
The  pecuHar  description  which  he  gave  of  the  pains  to 
which  he  was  subject  made  me  suspect  tabes  ;  and,  on 
examining  his  legs,  I  found  the  knee-jerk  absent,  which 
threw  at  once  a  flood  of  light  on  the  nature  of  his  malady. 
I  then  examined  him  for  other  symptoms  of  tabes,  and 
found  that  he  staggered  on  standing  with  his  eyes 
closed  ;  that  he  had  Argyll-Robertson's  symptom  of  re- 
flectory rigidity  of  the  pupil,  could  only  walk  with 
assistance,  had  lost  the  sexual  power  some  years  ago, 
and  suffered  frequently  from  incontinence  of  the  bladder 


140  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  the  bowels  ;  lie  had  regular  vesical  crises  from  time 
to  time,  when  he  would  be  seized  with  severe  pain  in  the 
bladder,  chiefly  at  night,  and  constant  desire  to  pass  his 
water.  On  some  occasions  he  had  been  called  out  of  bed 
more  than  sixty  times  in  the  course  of  a  single  night,  and 
would  each  time  pass  only  a  few  drops  of  water  in  great 
agony.  He  had  similar  rectal  crises,  and  would  soil  himself 
five  or  six  times  in  the  course  of  a  night.  The  upper  ex- 
tremities were  not  affected,  with  the  exception  of  an  area 
of  numbness  in  the  sphere  of  the  right  ulnar  nerve. 

Case  46. — In  July,  1883,  Dr.  Philpot,  of  Croydon,  asked 
me  to  see  a  gentleman  with  him,  who  wished  to  have  an 
entirely  unbiassed  opinion  on  his  case.     Dr.  Philpot  there- 
fore told  me  nothing  of  the  diagnoses  which  had  previously 
been  made,  until  after  I  had  finished  my  examination  and 
given  my  opinion.     The  patient  was  fifty-six  years  of  age, 
marriedj  and  father  of  two  children,  and  had  been  actively 
engaged  in  business.      His  chief  complaint  was  of  depres- 
sion of  spirits,  indigestion,  and  tightness  round  the  chest,, 
which  he  had  had  for  about  two  years.    A  feeling  of  constric- 
tion of  the   chest  being  a  prominent  symptom  of  tabes,  I 
examined  the  patellar  tendon  reflexes,  and  finding  them 
completely  absent,  had  no  difiiculty  in  eliciting  the  history 
and  presence  of  numerous  other  symptoms  of  that  complaint. 
It  appeared  that  the  patient  had  had  syphilis  ten  years  ago. 
Eight  years   afterwards,  he  began  to  complain  of  numb- 
ness in  the  third  and  fourth  fingers  of  both  hands  ;  of  dull 
pain  in  the  back  and  the  legs  ;  of  incontinence  of  urine, 
constipation  of  the  bowels,  and  loss  of  sexual  desire  and 
power.     In  addition  to  these   symptoms,   there  was  now 
reflectory  rigidity  of  the  pupils,  Romberg's  symptom,  diffi- 
culty in  going  downstairs,  a  sensation  as  if  there  were  a 
pad  of  india-rubber  under  his  soles,  and   slight  ataxy  in 
walking. 

In  the  following  case  the  patient  complained  chiefly  of 
sleeplessness  ;  and  the  symptoms  of  tabes  were  so  masked 


SYMPTOMS  OF  TABES  SPINALIS.  141 

that  it   would   have  been  impossible  to  arrive  at  a  correct 
diagnosis  without  Westphal's  symptom  : — 

Case  47. — An  officer,  aged  37,  single,  consulted  me  in 
December,  1881.  He  had  served  fourteen  years  in  India, 
and  suffered  there  during  the  whole  of  that  time,  more 
or  less,  from  "  congestion  of  the  liver "  and  diarrhoea. 
He  contracted  syphilis  in  1872.  Four  months  after  the 
appearance  of  the  primary  sore,  a  specific  eruption 
appeared  on  the  legs,  but  soon  faded  away  again.  Soon 
afterwards  he  had  to  complain  of  soreness  on  the 
edges  of  the  tongue  and  sore-throat ;  and  his  tongue 
has  remained  permanently  sore  ever  since.  For  this  he 
was  treated  by  iodide  of  potassium  only ;  he  never 
had  any  mercury  given  him.  Soon  afterwards  he  began 
to  suffer  from  severe  pains  about  the  loins,  which  he 
attributed  to  having  strained  the  muscles  of  his  back 
while  playing  rackets.  He  played  this  game  daily 
while  in  India,  and  also  indulged  freely  in  promiscuous 
sexual  intercourse.  In  1878  he  was  obliged  to  give  up 
rackets,  and  had  since  then  had  constant  pain  in  the  loins, 
and  that  in  any  position,  whether  sitting  or  lying,  standing, 
walking,  or  riding.  Sixteen  months  ago  insomnia  came  on, 
and  proved  most  obstinate.  At  the  same  time  he  began  to 
feel  a  distaste  for  sexual  indulgence,  society,  and  his  duties. 
He  also  had  a  feeling  of  *' fierce  compression  "  across  the 
chest.  He  returned  to  England,  and  remained  here  for  six 
weeks,  after  which  he  went  back  to  India.  Soon  after  his 
arrival  there,  a  feeling  of  intense  spinal  irritation  came  on, 
which  extended  up  and  down  the  entire  length  of  the  spine, 
and  was  accompanied  by  numbness  and  "pins  and  needles"  in 
the  hands  and  feet.  The  irritation  in  the  back  led  to  great 
nervousness  ;  the  patient  also  complained  of  overpowering 
lassitude  and  weakness  in  the  legs,  and  felt  it  impossible 
to  continue  his  duties.  He  once  more  returned  to  England 
in  April,  1881,  and  was  put  under  mercurial  treatment, 
which  however  did  him  no  good.      In  August  he  went  to 


142  SCLEROSIS  OP  THE  SPINAL  CORD. 

Grastein,  took  twenty-seven  baths,  and  was  galvanised,  also 
without  any  effect.  When  I  saw  him,  his  chief  complaint 
was  of  insomnia  and  great  hypereesthesia  of  the  back.  The 
latter  symptom  induced  me  to  examine  the  patellar  reflexes, 
which  I  found  to  be  absent  in  both  sides.  I  now  inquired 
for  other  symptoms  of  tabes,  and  found  that  he  had  numb- 
ness in  all  four  extremities  ;  considerable  debility  in  walk- 
ing, although  no  ataxic  gait;  the  muscles  of  the  legs  were 
thin  and  flabby  ;  and  the  sexual  power  and  desire  were 
greatly  diminished. 

While,  therefore,  the  loss  of  the  knee-jerk  habitually  in- 
dicates tabes  spinalis,  even  where  other  symptoms  seem  to 
point  in  a  different  direction,  its  presence  or  exaggeration 
will  show  us  that  although  many  symptoms  of  tabes  may 
be  present,  yet  the  case  is  not  one  of  locomotor  ataxy  or 
sclerosis  of  the  posterior  columns  of  the  cord,  as  generally 
understood.  In  such  cases  which  are  far  from  uncommon, 
we  have  rather  to  do  with  a  combined  system-disease  of 
the  lateral  and  posterior  columns,  or  with  disseminated  in- 
sular sclerosis,  than  with  true  tabes.  The  exaggeration  of 
the  knee-jerk  is  then  to  be  explained  by  the  sclerotic  irri- 
tation of  the  lateral  columns,  which  is  too  powerful  in  its 
effects  to  be  neutralised  by  the  disease  of  the  posterior 
columns.  Lightning  pains  are  mostly  absent,  and  the 
difficulty  in  walking  is  rather  owing  to  paresis  than  to 
ataxy,  or  to  a  combination  of  these  two  conditions. 

Case  48. — A  miller,  aged  thirty-one,  married,  and  father 
of  two  children,  was  admitted  into  the  hospital  under  my 
care,  in  February,  1883.  He  denied  any  syphilitic  in- 
fection, and  attributed  his  illness  to  severe  chills  which  he 
had  habitually  experienced  in  his  business.  Twelve  years 
ago  he  had  broken  his  right  leg,  and  there  was  now  a  large 
exostosis  on  the  tibia  which,  but  for  this  history,  might  have 
been  looked  upon  as  of  a  syphilitic  character.  His  present 
illness  commenced  three  years  ago,  when  he  lost  his  taste 
and  had  double  vision.     At  the   same  time  he  found  that 


SYMPTOMS  OF  TABES  SPINALIS.  143 

he  could  not  walk  so  well  as  before,  more  especially  in  the 
dark.     After  a  time  the  sense  of  taste  gradually  came  back 
and  he  saw  things  single  again  ;    and  two  months  after 
having  been  first  taken  ill,  the  power  in  the  legs  improved 
so   much  that   he   thought  he  walked   as    well    as  ever. 
Twelve  months  ago,  however,  he  began  to  get  worse  again, 
and  the  disease  has  since  then   gradually  gained  upon  him. 
On  examination  the  brain  and  cranial  nerves  appeared  to  be 
healthy.    The  patient  complained  of  a  sensation  as  if  he  had 
a  tight  rope  round  his  chest,  of  difficulty  in  retaining  the 
urine,  obstinate  constipation,  and  complete  loss  of  sexual 
power.     He  felt  numbness  in  the  hands,  and  some  deo-ree 
of  ataxy  in  the  upper  extremities,  more  especially  when  he 
attempted  to  write.     His  gait  appeared  to  be  a  mixture  of 
ataxy  and  paresis,  as  there  was  decided  loss  of  muscular  force, 
together  with  jerkiness  ;  the  patient  had  to  manoeuvre  with 
his  arms  while  walking,  as  otherwise  he  felt  too  unsteady 
to  go  on  ;  and  on  shutting  his  eyes  he  staggered  to  such  an 
extent  that  he  would  have  fallen  unless  supported.    He  also 
complained  of  numbness   in  the  soles  of  the  feet  ;   but  he 
had  never  had  lightning  pains,  or  indeed  any  other  kind 
of  pain.     On  testing  the  deep   reflexes,  I  found  them  all 
very  much  exaggerated  ;  and  I  therefore  concluded  that  the 
case  was  not  one  of  tabes  spinalis,  but  one  of  an  unusual 
form  of  insular  sclerosis  of  the  spinal  cord,  which  had  affected 
several  strands  of  fibres  in  that  organ,  but  had  spared  those 
which  are  more  particularly  concerned  with  the  sensation 
of  pain  and  the  conduction  of  reflex  action  in  the  posterior 
columns. 

The  absence  of  lightning-pains  is,  however,  not  invari- 
able in  such  cases,  as  shown  by  the  following  instance  : — 

Case  49. — An  Irish  farmer,  aged  fifty-one,  married,  and 
father  of  two  children,  consulted  me  in  October,  1 882.  He 
complained  of  incontinence  of  urine,  loss  of  sexual  power, 
obstinate  constipation  of  the  bowels,  inability  to  walk 
in  the  dark,  numbness,  and  occasional  attacks  of  lightning- 


144  SCLEROSIS  OF  THE  SPINAL  CORD. 

pains  in  the  legs,  the  muscles  of  which  were  exceedingly- 
flabby  and  wasted.  He  had  had  syphilis  rather  badly  ten 
years  ago.  He  was  seen  to  stagger  when  standing  with  his 
eyes  closed,  and  his  gait  was  a  mixture  of  ataxy  and  paresis. 
The  patellar  reflexes  were  greatly  exaggerated,  and  I  there- 
fore concluded  the  case  to  be  one  of  combined  system  disease 
of  the  lateral  and  posterior  columns. 

Case  50. — Another  case  in  which  there  was  a  marked 
combination  of  loss  of  power  and  ataxy,  was  that  of  an 
accountant,  aged  thirty-two,  single,  who  was  sent  to  me 
in  October,  1879,  by  Dr.  Haussmann,  of  Wildbad.  This 
patient  had  "knocked  about  town"  a  good  deal  about 
ten  years  ago,  and  had  then  had  a  chancre  which  was  fol- 
lowed by  a  large  crop  of  "  secondaries,"  chiefly  on  the 
skin  and  in  the  throat.  Two  years  afterwards  he  had 
repeated  attacks  of  hemiplegia  and  aphasia,  and  was  in- 
efficiently treated  in  Java,  the  Cape,  St.  Helena,  and 
various  places.  He  got  better  and  worse,  off  and  on, 
but  about  three  years  ago  began  to  suffer  from  more 
definite  symptoms  of  spinal  disease.  He  had  now  the 
greatest  difficulty  in  getting  up  from  a  chair,  in  stand- 
ing and  walking.  There  was  great  loss  of  muscular 
power,  more  particularly  in  the  right  leg.  The  bladder 
was  so  irritable,  that  he  felt  constant  desire  to  pass  his 
water,  and  he  wetted  the  bed  in  his  sleep.  The  bowels 
were  obstinately  constipated ;  the  sexual  power  almost 
entirely  lost.  The  knee-jerk  was  greatly  exaggerated 
in  both  sides  ;  and  it  was  therefore  evident  that  the  case 
was  one  of  combined  system-disease  of  the  cord.  In 
this  case,  likewise,  no  lightning  pains  had  occurred  at 
any  time. 

Does  the  hnee-jerh,  when  once  lost,  ever  come  bacJc  ? 
There  is  very  little  positive  experience  about  this,  but 
a  great  deal  of  negative  evidence.  In  general,  I  may  say 
that  it  never  returns  in  cases  of  ordinary  tabes  ;  but  I 
have  seen  it  return,  under  the  influence  of  treatment,  in 


SYMPTOMS  OP  TABES  SPINALIS.  145 

cases  of  combined  cerebral  and  spinal  disease,  which  pre- 
sented themselves  nnder  the  clinical  aspects  of  general 
paralysis  of  the  insane  in  the  first  period  of  the 
complaint,  more  especially  where  this  was  owing  to 
syphilis.  In  a  case  of  this  kind,  in  which  I  was  con- 
sulted in  April,  1884,  and  where  the  absence  of  the 
linee-jerk,"'together  with  grave  cerebral  symptoms,  appeared 
-to  afford  a  gloomy  prognosis,  the  patellar  reflex  returned, 
under  the  influence  of  an  energetic  specific  treatment, 
within  a  fortnight,  together  with  great  improvement  in 
other  respects.  I  have  at  present  (May,  1884)  a  patient 
suffering  from  the  effects  of  injury  to  the  spine  under  my 
care,  at  the  hospital,  in  whom  the  accident  had  caused 
paresis  of  the  lower  extremities.  The  knee-jerk  was  at 
first  exaggerated,  but,  as  time  went  on,  became  more  and 
more  sluggish,  and  eventually  vanished  altogether.  The 
patient,  who  had  at  first  been  treated  with  iodide  of  potas- 
sium, was  now  put  on  full  doses  of  ergot ;  and,  after  he 
had  taken  this  for  six  weeks,  the  reflex  could  again  be 
elicited.  At  the  same  time  there  had  been  proportionate 
improvement  in  the  motor  power  of  the  lower  extremities 
all  the  time  that  the  patient  was  taking  the  ergot. 

With  regard  to  this  point  Westphal  has  drawn  attention 
io  a  source  of  error,  which  consists  of  confounding  certain 
skin-reflexes  with  the  true  knee-jerk.  Contraction  of  the 
quadriceps  femoris  may  occasionally  be  caused  by  pinching 
.a  fold  of  the  skin  in  the  neighbourhood  of  the  patellar 
tendon,  or  percussing  it  sideways,  without  touching  the 
patellar  tendon  itself.  In  some  persons  all  the  muscles 
of  the  thigh  are  seen  to  contract  if  the  skin  above  the 
internal  malleolus  be  strongly  pinched.  There  is,  there- 
fore, a  "  pseudo-knee-jerk  ; "  and  whenever  it  is  reported 
that  the  knee-jerk  has  returned,  it  must  be  plainly  stated 
that  the  observer  has  not  been  deceived  by  cutaneous 
reflexes. 

Eulenburg  and  Striimpell  have  seen  the  patellar  reflex 

L 


146  SCLEROSIS  OF  THE   SPINAL  CORD. 

return  after  stryclinia  injections.  Dowse  ^  believes  that  he 
has  "  restored  the  lost  knee-jerk  instanter  by  passing  a  con- 
tinuous current  freely  though  the  spinal  cord."  This  is  a 
startling  assertion,  but  hardly  less  so  than  another  state- 
ment by  the  same  author,  "  that  the  knee-jerk  and  all  other 
reflexes  are  not  uncommonly  exaggerated  in  the  earlier 
stage  of  tabes,  and  that  this  may  be  accounted  for 
by  the  possible  probability  (sic)  that  the  changes  in  the 
posterior  root-zones  are  extremely  peripheral,  and  invade 
more  or  less  the  adjacent  matter  of  the  lateral  columns.'* 
Tabes  is  here  evidently  confounded  with  insular  sclerosis, 
or  some  other  form  of  combined  system-disease  of  the 
cord  ;  while  the  "  instantaneous  recovery  of  the  knee-jerk 
by  the  passage  of  an  electric  current  through  the  spine  " 
would  presuppose  an  immediate  cure  by  that  means  of 
a  definite  anatomical  lesion  in  the  lumbar  portion  of  the 
cord,  which  is,  unfortunately  for  our  patients,  too  stubborn 
in  character  to  yield,  so  readily  as  has  been  assumed,  to  a 
single  application  of  electricity. 

Loss  of  the  knee-jerk  on  one  side  appears  to  be 
extremely  rare.  Even  where  the  other  clinical  symptoms 
have  been  entirely  limited  to  one  side  of  the  body,  thus 
constituting  a  kind  of  hemi-ataxy,  I  have  invariably  found 
the  loss  of  the  knee-jerk  to  be  bilateral,  even  at  an  early 
period  of  the  malady.  A  few  other  observers  have,  how- 
ever, apparently  seen  the  phenomenon  absent  on  one  side, 
and  present  on  the  other. 

2.  Lightning- Pains. — This  term  is  well  suited  for  de- 
scribing the  exceedingly  violent  and  sudden  nature  of 
the  pain  which  is  so  commonly  experienced  in  tabes. 
Synonyms  are  "  lancinating  "  and  "  fulgurating  "  pains. 
Some  patients  compare  these  sensations  to  electric 
shocks  ;  others  describe  them  as  violent  blows  with  a 
heavy  hammer,  or  kicks,  or  nails  driven  into  the  flesh,  or 

»  "  Medical  Times  and  Gazette,"  October  1,  1881. 


SYMPTOMS    OF    TABES    SPINALIS.  147 

as  if  a  red-liot  corkscrew  were  turned  roimd  in  the  limbs, 
or  like  a  sudden  contact  with  a  red-hot  iron,  or  as  if  they 
were  bitten  by  dogs,  gnawed  by  rats,  or  as  if  the  flesh 
were  forcibly  torn  from  their  bones,  or  as  if  their  bones 
were  crushed  in  a  press,  or  their  insides  burnt  with  fire, 
or  as  if  they  were  actually  being  impaled,  or  as  if  they 
were  struck  by  a  dagger  or  stabbed  with  a  knife, 
or  as  if  thousands  of  fish-hooks  had  got  hold  of  the 
calves  of  the  legs,  and  were  dragging  them  up.  Pains 
of  this  kind  are  apt  to  come  on  suddenly,  chiefly  at 
night,  and  in  paroxysms,  so  that  a  shock  is  experienced 
every  few  seconds  or  every  few  minutes  ;  and  they  vanish 
after  a  variable  time  as  quickly,  and  often  without  any 
apparent  cause.  In  their  greatest  degree  of  violence  they 
constitute  the  most  frightful  torture  which  can  be 
imagined,  and  which  renders  life  utterly  wretched  and 
intolerable.  The  patients  actually  writhe  with  pain, 
scream,  call  for  mercy,  twist  themselves  into  various 
positions,  squeeze  the  painful  spots  as  hard  as  they 
can,  and,  when  the  attack  is  over,  seem  to  be  half-dead 
from  exhaustion.  As  such  paroxysms  occur  chiefly  at 
night,  they  prevent  the  patient  from  sleeping,  and  thus 
aggravate  the  general  disturbance  of  the  system  which  is 
the  consequence. 

Charcot  distinguishes  lightning  pains,  which  run  like 
lightning  shocks  through  the  course  of  a  nerve  or  a  limb  ; 
and  terehrating  or  boring  pains,  which  are  of  the  dagger- 
and-cork-screw  character,  and  mostly  occur  near  a  joint. 
This  distinction,  however,  is  imperceptible  in  a  number  of 
cases,  as  both  forms  may  occur  together. 

Another  form  of  pain  is  less  violent  and  more  constant. 
This  is  generally  fixed  in  a  certain  locality.  For  in- 
stance, there  is  a  dull  back-ache,  a  pain  between  the 
shoulders  or  in  the  spine,  and  spreading  from  there  to 
the  sides  of  the  body  ;  or  both  legs  suffer  in  the  same 
manner,  so    that  the  patient  is  believed  to  have  bilateral 

l2 


148  SCLEROSIS  OP  THE  SPINAL  COED. 

sciatica.  This  aching  may  also  come  on  in  crises,  and 
continue  for  a  few  days  or  weeks.  Occasionally  the 
pain  is  not  really  constant,  but  consists  of  a  series  of 
acute  paroxysms  following  each  other  rapidly.  The 
more  paroxysmal  and  the  more  constant  pain  may  alter- 
nate in  the  same  patient.  * 

A  third  kind  of  pain,  which  is,  according  to  Fournier, 
chiefly  felt  by  syphilitic  subjects,  is  of  a  much  slighter 
character,  and  comes  at  longer  intervals.  This  resembles 
a  slight  prick  with  a  pin,  apparently  hardly  going  beyond 
the  epidermis,  or  a  slight  pinching  of  the  flesh.  It  is 
so  insignificant  that  patients  take  little  notice  of  it,  but 
remember  it  afterwards,  when  they  may  be  suffering  from 
more  severe  paroxysms.  There  are  often  long  intervals 
between  these  slight  attacks,  which  come  on  for  a  few 
liours  only,  once  in  two  or  three  or  even  six  months. 
Unless  a  specific  treatment  be  instituted,  however,  the 
pain  is  liable  to  become  much  worse  as  time  goes  on, 
and  to  occur  at  much  shorter  intervals. 

The  principal  seat  of  all  these  different  kinds  of  pain  is 
in  the  lower  extremities,  where  they  are  almost  invariably 
felt  in  the  commencement  of  the  disease,  and  where  they 
may  continue  to  rage  with  unabated  fury  from  time  to  time 
for  years.  They  may  shoot  all  the  way  down  from  the 
hips  to  the  toes,  or  follow  a  certain  nervous  distribution, 
as  in  neuralgia,  or  affect  a  limited  area,  such  as  the  ankle, 
the  knee,  thigh,  or  hip.  If  they  are  localised  in  a  small 
space,  hyperaesthesia  is  apt  to  supervene  in  the  same,  so 
that  the  least  touch  is  exceedingly  painful,  while  strong 
pressure  is  apt  to  relieve  the  pain.  Occasionally  an  ery- 
thematous rash  or  circumscribed  urticaria  breaks  out  in  such 
a  spot  after  the  pain  has  been  going  on  for  some  time  ;  and 
Charcot  has  seen  ecthyma  in  the  sphere  of  the  crural  and 
internal  saphenous  nerve,  leaving  scars  which  have  been 
visible  for  years.  Muscular  twitches  in  the  neighbourhood 
testify  to  the  increased  reflex  excitability  which  is  gradually 


SYMPTOMS  OF  TABES  SPINALIS.  149 

established.     Occasionally  a   shock  through  the  legs  is  so 
sudden  that  the  patient,  if  walking  or  standing  at  the  time, 
drops  down  as  if  he  were  shot,  and  is  believed  to  have  a 
fit.     Sometimes   the   pain  affects,  even  in  the  beginning, 
other  parts   than   the  lower  limbs,  such   as   the  back,  the 
upper  extremities,  the  body,  and  the  head.   When  affecting 
the   chest,  it   often  resembles  intercostal  neuralgia,  or  the 
pain  of  herpes  zoster.     In  a  considerable  number  of  cases 
the  pain   appears  to  follow  very   closely  the   anatomical 
changes   going   on  in   the   cord  ;  and  as   these   are  apt  to 
spread  from  below  upwards,  so  the  pain,  after  having  been 
for  some  time  confined  to  the  lower  extremities,  gradually 
invades  the  abdomen,  chest,  the  upper  extremities,  and  the 
head.     It  is  sometimes  confined  to  one  limb  or  one  side  of 
the  body,  and  sometimes  to  the  upper  extremities.    In  such 
cases   the  other   symptoms  of  tabes   which   follow  in  the 
further  course  of  the  disease   are  apt  to  show  a  similar 
distribution,   showing  that  they  follow  pretty  closely  the 
anatomical    process    as   it   spreads     further    in    the    sub- 
stance of   the  cord.     In   the  upper   extremities   the   area 
of  the  ulnar   nerve  is  affected  by  preference,  the   shocks 
running  from  the  olecranon  down  into  the  third  and  fourth 
finger. 

Pains  in  the  face  and  head,  to  the  occurrence  of  which  in 
tabes  Pierret^  was  the  first  to  draw  attention,  present  the 
same  character  as  the  pains  in  the  limbs,  being  either 
paroxysmal,  in  the  form  of  lightning  pains,  or  more  conti- 
nuous. The  latter  are  by  far  the  more  frequent,  and  affect  the 
top  of  the  head,  the  temples,  the  bridge  of  the  nose,  the  audi- 
tory meatus,  the  jaw,  lips,  and  teeth,  or  the  occipital  region. 
Some  patients  have  a  sensation  as  if  the  eye  were  suddenly 
torn  from  its  socket,  or  feel  a  sudden  stab  or  shock  right 
through  the  head  or  in  the  orbit.    This  may  be  accompanied 

1  "Essai  sur  les  Symptomes  cephaliques  du  Tabes  dorsalis,"  p.  21. 
Paris,  1876. 


loO  SCLEROSIS  OF  THE  SPINAL  CORD. 

with  laciymation,  photophobia,  and  certain  vaso-motor  symp- 
toms, snch  as  congestion  of  the  conjunctiva,  dilatation  of  the 
pupil,  and  elevation  of  temperature  ;  others  see  flames  and 
flashes  of  light,  showing  that  the  optic  nerve  participates 
in  the  irritation.  Sometimes  the  pain  is  confined  to  one 
side  of  the  head,  and  resembles  megrim.  It  is  rebellious  to 
treatment,  often  lasts  a  long  time,  and  then  suddenly  disap- 
pears without  any  apparent  cause.  It  is  therefore  important 
to  remember,  in  cases  of  what  is  called  facial  neuralgia,  that 
this  may  be  an  early  symptom  of  tabes. 

We  have  seen  (p.  28)  that  the  nucleus  of  the  fifth  nerve 
has  been  found  wasted  in  tabes  by  Hayem  and  Pierret,  but 
that  it  is  as  yet  uncertain  whether  this  nerve  suffers  in  its 
peripheral  course.  Pierret  explains  the  pain  which  is,  in 
tabes,  experienced  in  the  sphere  of  the  fifth  nerve,  by 
sclerosis  of  the  descending  root  of  the  same,  which  may 
be  traced  down  in  the  cord  as  far  as  the  level  of  the 
third  or  fourth  cervical  nerve  ;  while  the  pain  at  the  back 
of  the  head,  in  the  sphere  of  the  occipital  nerve,  would  be 
accounted  for  by  this  nerve  being  the  internal  branch  of 
the  posterior  division  of  the  second  cervical  nerve.  Thus, 
the  lesion  causing  these  pains  would  be  central,  bilateral,  and 
symmetrical,  and  this  would  be  in  accordance  with  the  fact 
that  the  facial  neuralgia  of  tabes  is  not  generally  so  confined 
to  a  single  branch  of  the  trifacial  as  it  is  in  idiopathic  neur- 
algia, but  may  play  about  in  the  entire  area  supplied  by  the 
fifth  pair. 

In  general,  pains  of  extreme  violence  are  temporary,  but 
apt  to  recur  at  short  intervals.  In  this  respect  there  are  the 
greatest  possible  varieties  in  individual  cases.  Occasionally 
the  intervals  are  very  long,  amounting  to  six  months  and  more; 
and  there  is  generally  an  exciting  cause  to  be  discovered  for 
a  "  bout  of  pain."  In  this  country  it  is  chiefly  the  easterly 
winds  of  March  and  April,  and  a  sudden  change  to  wet 
weather  at  any  time  of  the  year,  or  thunderstorms,  which 
are  dreaded  by  tabid  patients.     Other  exciting  causes  are 


SYMPTOMS  OF  TABES  SPINALIS.  lol 

sudden  emotions,  more  especially  annoyance,  over-exertion, 
sexual  indulgence,  and  nocturnal  seminal  emissions.  In  ex- 
ceptional cases  pain  of  any  sort  may  be  absent  throughout 
the  first  stage  of  the  disease;  or  it  may  be  so  slight  that 
the  patient  forgets  all  about  it,  or  simply 'says  that  he  may 
have  had  a  little  rheumatism. 

Topinard  has  found  these  pains  altogether  absent  in 
twenty-two  cases  out  of  a  hundred  and  four  ;  and  Erb  in 
eight  cases  out  of  sixty.  According  to  my  experience  they 
are  almost  invariably  present  in  really  well-marked  cases 
of  tabes,  while  they  are  absent  in  those  patients  who, 
although  presenting  many  symptoms  of  sclerosis  of  the 
posterior  columns,  appear  to  be  subject  to  combined  system- 
diseases  of  the  cord,  or  insular  sclerosis.  I  have  already 
drawn  attention  to  the  circumstance  that,  where  the  knee- 
jerk  is  exaggerated  instead  of  being  lost,  lightning  pains 
are  habitually  absent  (p.  142). 

On  the  other  hand,  we  find  that  they  are  not  absolutely 
limited  to  tabes,  but  that  they  may  occur  whenever  the 
posterior  columns,  and  more  particularly  Burdach's  strands, 
are  affected.  Thus  they  have  been  observed  in  myelitis 
and  meningo-myelitis,  where  this  was  either  spontaneous  or 
consecutive  to  Pott's  disease  of  the  vertebra  ;  in  some 
forms  of  insular  sclerosis,  of  general  paralysis  of  the  insane, 
of  chronic  alcoholism,  and  in  alcohoHc  paraplegia.  Again, 
in  certain  forms  of  sciatica  and  tic-douloureux,  the  pain  is 
so  similar  to  lightning  pains,  that  it  would  be  impossible, 
from  this  symptom  alone,  to  make  a  distinction.  In  such 
cases  the  seat  of  the  neuralgia  is  probably  more  central 
than  peripheral,  and  located  in  the  posterior  nerve-roots. 

Charcot  was  the  first  to  express  the  opinion  that  the 
lightning-pains  in  tabes  are  owing  to  sudden  irritation  of 
the  posterior  nerve-roots,  in  the  root-zones  of  the  posterior 
columns  ;  and  this  explanation  is  so  plausible  that  it  has 
been  generally  accepted.  We  could,  with  this  theory, 
easily  account  for  the  varying  degrees  of  intensity  of  the 


152  SCLEROSIS  OF  THE  SPINAL  CORD. 

pain,  by  assuming  a  corresponding  degree  of  irritation  in 
Burdacli's  columns  ;  while  the  differences  in  the  seat  of  the 
pain  would  be  explained  by  the  different  areas  of  root- 
fibres  in  the  cord  which  might  happen  to  be  subject  to 
irritation.  That  the  pain  should  not  be  felt  so  much  in 
any  portion  of  the  back  as  in  the  peripheral  expansions  of 
the  spinal  nerves  is,  as  Yulpian  has  appositely  remarked,  in 
accordance  with  the  general  law,  which  ordains  that  im- 
pressions produced  in  the  cord,  or  at  any  portion  of  the 
nerve,  are  by  the  brain  referred  to  the  periphery.  Pain, 
although  produced  in  the  centre,  is  felt  in  the  skin,  and 
sometimes  in  such  a  limited  area  of  the  skin  that  the  patient 
is  loth  to  believe  that  it  really  arises  from  irritation  in  the 
spinal  cord,  when  he  feels  no  pain  whatever  in  the  spine. 
This,  however,  is  likewise  the  case  in  certain  forms  of 
neuralgia,  such  as  tic,  intercostal  neuralgia,  and  sciatica,, 
where  the  pain  is  produced  in  the  nervous  centres,  or  the 
nerve-roots,  or  the  spinal  canal,  or  the  skull,  while  it  is  per- 
ceived peripherally.  This  will  explain  why  neurotomy  and 
neurectomy  of  the  apparently  affected  nerve  are  so  often 
unsuccessful. 

The  theory  of  the  central  production  of  lightning-pains 
is  apparently  contradicted  by  the  fact  that  these  pains  may 
be  relieved  by  certain  local  applications  to  those  parts  of 
the  skin  in  which  they  are  experienced.  Such  applications 
may  be  of  the  most  varied  character  ;  the  chief  amongst 
them  being  counter-irritants,  such  as  blisters,  sinapisms,  hot 
fomentations,  and  chloroform,  subcutaneous  injections  of 
morphia  and  atropia,  and,  what  seems  more  extraordinary 
still,  injections  of  plain  water  into  the  cellular  tissue.  This 
contradiction,  however,  is  only  apparent,  as  will  be  seen 
from  the  following  considerations: — 

It  is  a  well-known  fact  that  the  pains  of  tabes  are  apt  to 
be  made  worse  by  a  slight  touch  of  the  parts  in  which  they 
are  experienced,  while  strong  pressure,  on  the  contrary, 
gives  relief.    The  tabid  patient,  when  subject  to  a  paroxysm 


SYMPTOMS  OF  TABES  SPINALIS.  15^ 

of  lightning-pains,  is  therefore  generally  seen  to  squeeze 
the  parts  aSected  as  hard  as  he  is  able.  In  order  to  under- 
stand this,  we  must  remember  that  waves  of  nervous  in- 
fluence' are  constantly  transmitted  from  the  peripheral 
expansions  of  the  sentient  nerves  to  the  nervous  centres  ; 
and  these  play,  unquestionably,  a  considerable  part  in  the 
causation  of  the  pains  of  tabes.  We  know  that  changes  in 
the  weather,  a  thunderstorm,  or  the  simple  influence  of  cold, 
will  give  rise  to  a  paroxysm  of  lightning-pains.  In  a  healthy 
person  the  influence  of  such  waves  of  nervous  force  passes,. 
in  general,  unperceived  ;  but  when  nervous  elements  are 
traversed  which  are  in  a  state  of  morbid  irritation,  pain  is 
caused.  Nothing  can  be  more  intimate  than  the  relation 
which  exists  between  the  suffering  posterior  nerve-roots,  on 
the  one  hand,  and  the  peripheral  sentient  nerves  in  the 
skin,  the  subcutaneous  cellular  tissue,  the  muscles,  and  even 
the  periosteum  of  those  parts  where  the  pain  is  experienced, 
on  the  other  hand.  An  injection  of  morphia  and  atropia 
has  no  doubt  a  general  influence  in  subduing  undue  ex- 
citability in.  the  posterior  columns  and  nerve-roots  ;  but 
its  power  of  relieving  the  pains  of  ataxy  is  also  to  some 
extent  owing  to  a  kind  of  local  ansesthesia  which  is  caused 
in  the  peripheral  fibres  near  which  the  injection  is  made. 
The  fibres  which  are  in  direct  contact  with  the  liquid  in- 
jected, are  being  temporarily  paralysed  bj  the  narcotic  ;  and 
complete  or  incomplete  anaesthesia  of  the  skin,  in  a  circum- 
ference of  an  inch  or  two  in  diameter,  may  be  found 
there,  and  may  last  for  several  minutes.  In  consequence 
of  this,  the  waves  of  nervous  irritation,  which  were 
transmitted  by  those  fibres  to  the  suffering  centres,  are 
for  the  time  being  diminished  or  suppressed.  Hence  it 
rcBults  that  the  paroxysm  ceases  in  the  centre,  and  the  pain 
disappears.  The  pain  may  not  even  return  when  the  local 
anaesthesia  in  the  area  of  injection  has  disappeared,  partly 
because  the  irritation  of  the  roots  has  ceased,  and  partly 
because   the    general  effect  of  the  morphia  and    atropia, 


154  SCLEROSIS  OF  THE  SPINAL  CORD. 

which  now  arrive  with  the  blood  at  the  suffering  parts,  is 
superadded  to  the  local  action. 

Ranvier  has  shown  that  when  a  nerve  of  an  animal  is 
laid  bare  and  subjected  to  the  action  of  plain  water  for 
some  time,  say  a  few  minutes,  it  loses  its  physiological 
properties,  probably  from  swelling  of  the  axis-cylinders  of 
the  nerve-fibre  through  the  imbibition  of  fluid.  It  is  no 
doubt  in  a  similar  way  that  injections  of  plain  water 
into  the  cellular  tissue  of  a  region  affected  with  pain  are 
effective  in  relieving  the  latter.  The  effect  is  therefore  not 
simply  owing  to  the  imagination  of  the  patient,  as  has  been 
generally  supposed  ;  but  the  afferent  nerve-fibres,  bathed  in 
water,  lose  for  a  time  their  excitability  and  conducting 
power,  and  therefore  cease  to  transmit  waves  of  irritation 
to  the  centres. 

The  influence  of  chloroform  and  other  counter-irritants  in 
relieving  the  lightning-pains  has  to  be  differently  explained. 
It  is  a  suggestive  fact  that  such  substances  produce  their 
effect  chiefly  when  they  cause  a  considerable  degree  of  local 
irritation  and  rubefaction,  and  much  less  so  when  the  skin — 
as  is  the  case  in  the  later  stages  of  tabes — has  become 
anaesthetic,  and  when  the  local  effect  which  is  produced  is 
less  powerful  or  altogether  absent.  It  has  been  stated  that 
counter-irritation  of  the  skin  produces  a  contraction  of  the 
blood-vessels  in  those  portions  of  the  posterior  roots  and 
columns  which  are  in  special  relation  with  the  peripheral 
nerves  acted  upon,  and  that  the  anaemia  thus  caused  in  the 
suffering  parts,  tends  to  relieve  the  irritation.  This,  how- 
ever, is  pure  speculation.  Brown- Sequard  believes  that  he^ 
has  produced  contraction  of  the  arterioles  of  the  spinal  pia 
mater  by  irritation  of  the  supra-renal  capsules  ;  but  sub- 
sequent observers  have  been  unable  to  corroborate  his 
results ;  and  even  supposing  that  such  a  contraction  took 
place,  this  would  not  prove  that  the  irritation  of  the  posterior 
roots  and  columns  could  thereby  be  diminished  or  arrested. 
A  far  more  plausible  explanation  is  that  given  by  Vulpian, 


SYMPTOMS  OF  TABES  SPINALIS.  155 

viz.,  that  the  pain  is  relieved  owing  to  a  powerful  impression 
being  produced  on  the  peripheral  cutaneous  nerves,  which 
the  latter  transmit  to  the  posterior  roots  and  columns, 
thereby  profoundly  modifying  their  condition.  Whether 
this  modification  of  the  molecular  state  of  the  central  parts 
is  more  or  less  permanent  or  temporary  must  depend  upon 
individual  circumstances.  It  will,  however,  be  seen  from 
the  foregoing  considerations  that  when  we  find  local  appli- 
cations useful  in  cases  of  neuralgia,  in  the  anaemic,  the  hy- 
sterical, the  rheumatic,  the  syphilitic,  and  the  alcoholised, 
this  result  does  by  no  means  prove  that  the  seat  of  the  pain 
was  local,  but,  on  the  contrary,  that  the  seat  of  the  pain  is 
likely  to  be  central  rather  than  peripheral. 

Lightning-pains  are  also  apt  to  occur  in  diverse  viscera, 
constituting  gastric,  laryngeal,  vesical,  rectal,  and  other 
"  crises  " ;  but  as,  in  accordance  with  the  localisation  of 
these  pains,  a  great  variety  of  other  symptoms  are  observed, 
I  consider  it  preferable  to  discuss  these  symptoms  separately, 
further  on. 

3.  Reflectory  Rigidity  of  the  Pupil  {Argyll- Robertson's 
Symptom). — The  condition  of  the  iris  varies  considerably  in 
the  initial  stage  of  tabes.  Quite  in  the  beginning  the  pupils 
are  apt  to  be  rather  large  than  small.  Mydriasis  in  one  eye 
I  have  known  to  be  one  of  the  first  symptoms  of  the  disease, 
but  the  most  peculiar  and  characteristic  change  which  occurs 
in  the  pupils  in  this  malady  is  that  which  was  first  de- 
scribed by  Argyll-Robertson,!  of  Edinburgh,  and,  therefore, 
bears  his  name.  It  consists  of  bilateral  myosis,  or  con- 
traction of  the  pupils,  with  loss  of  reflex  action  to  the 
influence  of  light,  but  with  preserved  voluntary  contraction 
during  accommodation.  The  symptom  is,  therefore,  seen 
to  be  closely  analogous  to  the  loss  of  the  knee-jerk,  where 
reflex  action  is  lost,  while  voluntary  power  remains,  and 
which  we  have  seen  to  be  a  sign  of  the  first  importance  in 
tabes. 

'  "Edinburgh  MedicalJoumal,"  p.  696,  Feb.  1869. 


156  SCLEROSIS  OF  THE  SPINAL  CORD. 

Argyll-Robertson  has  placed  on  record  the  case  of  a 
carver,  aged  fifty-nine,  who  was  then  evidently  in  the 
second  stage  of  tabes,  and  in  whom  he  noticed  that  both 
pupils  were  contracted  to  little  more  than  pin-points,  and 
did  not  contract  under  the  influence  of  light,  but  did  so 
when  the  patient  was  told  to  accommodate  the  eyes  for  a 
near  object.  The  pupils  dilated  only  slightly  under  the 
influence  of  a  four-grain  solution  of  atropine  ;  and  although 
this  was  re-applied  the  next  day,  it  failed  to  produce  any 
further  change  ;  its  action,  moreover,  was  transient,  even 
the  limited  dilatation  soon  disappearing.  Calabar  bean,  on 
the  other  hand,  produced  further  contraction  of  the  pupil, 
reducing  its  diameter  to  rather  less  than  one-fourth  of  a  line,, 
which  is  more  than  is  produced  in  other  cases  by  the  same 
agent.  The  right  eye  was  quite  colour-blind ;  but  with  the  left 
the  patient  could  distinguish  blue,  and  generally  the  other 
colours  when  of  a  bright  tint,  although  even  then  he  made 
occasional  mistakes,  having  a  tendency  to  call  all  colours  of 
which  he  was  uncertain  yellow  or  gilt.  This  symptom  had: 
been  a  source  of  annoyance  to  the  man,  as  it  prevented  him 
from  distinguishing  different  woods,  such  as  birch  and 
mahogany.  Neither  eye  was  abnormally  sensitive  to  light,, 
and  vision  was  best  in  bright  daylight.  His  field  of  vision 
was,  however,  markedly  contracted  in  both  eyes. 

Argyll-Robertson  attributed  this  condition  to  disease  of 
the  cord  affecting  the  cilio- spinal  region,  and  thought  it 
owing  not  to  spasm  of  the  sphincter,  but  to  paralysis  of 
the  dilator  muscle  or  the  radiating  fibres  of  the  iris.  He 
was  not  the  first  to  observe  myosis  in  cases  of  tabes  ;  for 
Romberg  had  previously  noticed  that  in  such  patients  the 
pupils  are  often  contracted  to  the  size  of  a  pin's-head  ; 
while  Trousseau  had  seen  the  same,  and  also  found  this 
contraction  to  resist  the  influence  of  belladonna,  and  that 
during  paroxysms  of  pain  the  contraction  was  replaced  by 
more  or  less  dilatation  of  the  pupil. 

The   symptom  which  we   are  now    discussing   appears. 


SYMPTOMS  OF  TABES  SPINALIS.  157 

to  be  very  frequent.     Vincent^  found  morbid   changes   in 
the  pupils  in  forty-seven  out  of  fifty-one  tabid  patients  (or 
ninety-two  per  cent.),  the  action  of  the  iris  having  been 
normal  in  only  four  cases.     Of  the  forty-seven  there  were 
forty  in  which  the  pupils  had  lost  the  light  reflex,  but 
acted   during    accommodation,   while   in    seven  they  were 
completely  immovable.      Of  the    forty   cases    where  the 
light-reflex  was  lost,  there  were  twenty-three  with  myosis, 
fiix  with   mydriasis,  and  eleven  with  normal  size  of  the 
pupils.     The  percentage  for  Argyll-Robertson's  symptom 
was,  therefore,  4:6'6.    With  regard  to  the   different  stages 
of  the  malady,  he  found  that  in  the  initial  period  the  pupils 
are  frequently  enlarged,  and  do  not  respond  to  the  influence 
of  light,  but  to  accommodation  ;  that  in  the  second  period 
there  is   generally  myosis  and  no  response  to  light,  but 
that  the  pupils  contract  for  near  objects  and  dilate  for  far 
objects  ;  while  in  the  third  or  terminal  period  the  pupils  are 
generally  dilated  or  of  normal  size,  and  completely  motion- 
less.    In  nine  cases  of  other  diseases  of  the  cord  and  the 
brain  he  found  good  response  to  light  eight  times  ;  while  in 
twenty-one  cases  of  general  paralysis  of  the  insane  he  found 
loss  of  the  light-reflex,  and  preserved  contraction  during 
accommodation  nineteen  times ;  in  seventeen  cases,  however, 
the  pupils  were  unequal,  while  there  was  myosis  in  eight, 
and  slight  mydriasis  in  three.     While,  therefore,  tabes  and 
general  paralysis  have  the  loss  of  the  light-reflex  in  common, 
they  differ  widely  from  one  another  by  the  pupils  being 
generally  of  equal  size  in  tabes   and  unequal  in  general 
paralysis. 

Erb^  has  seen  spinal  myosis  in  sixteen  cases  out  of 
thirty  (54  per  cent.),  and  I  have  seen  it  thirty-two  times 
in  fifty  consecutive  cases  (60*4  per  cent.). 

*  "  Des  Phenomenes  oculo-pupillaires  dans  I'Ataxie  locomotrice.'* 
These  de  Paris,  1877. 

^  "  Deutsches  Archiv  fiir  klinische  Medicin,"  vol.  xxiv.,  p.  31. 
Leipzig,  1879. 


158  SCLEROSIS  OF  THE  SPINAL  CORD. 

Where  the  pupil  is  much  contracted,  there  are  often  other 
signs  of  paralysis  of  the  vasomotors  :  such  as  a  red  cheek, 
an  injected  conjunctiva,  and  increased  temperature  of  the 
face.  During  paroxysms  of  pain,  the  contracted  pupil, 
however,  becomes  dilated,  and  the  symptoms  of  vasomotor 
paralysis  disappear.  The  ordinarily  unexcitable  pupil  may 
be  excited  reflexly  if  one  eye  is  closed  and  its  lid  lubricated 
with  the  tip  of  the  forefinger  and  pressed  ;  then  the  pupil 
of  the  opposite  eye  is  seen  to  dilate  considerably.  The 
same  occurs  when  the  skin  of  the  temples,  or  mastoid  pro- 
cesses is  faradised  with  the  brush. 

The  exact  mode  of  production  of  Argyll-Robert- 
son's symptom  is  not  yet  satisfactorily  explained.  It 
seems  quite  clear  that  the  pupils  are  contracted  from 
paralysis  of  the  radiating  fibres  of  the  iris,  or  dilators  of 
the  pupils,  while  the  circular  fibres  of  the  iris,  or 
sphincters  of  the  pupils,  remain  intact,  and  therefore 
show  predominance  of  action.  If  there  were  actual 
spasm  of  the  circular  fibres,  the  maximum  of  contrac- 
tion of  the  pupils  would  be  reached,  which  is  not 
the  case,  seeing  that  they  may  be  made  to  contract  still 
further,  both  during  efforts  at  accommodation  and  by 
the  influence  of  Calabar  bean.  Now  the  circular  fibres 
are  innervated  by  the  third  nerve,  while  the  radiating 
fibres  are  supplied  by  the  sympathetic.  Paralytic  myosis 
may  therefore  arise  from  disease  of  the  sympathetic 
root  of  the  lenticular  ganglion,  or  from  tumours  pressing 
on  the  cervical  sympathetic  nerve,  or  from  disease  of 
the  cilio-spinal  region  of  the  cord.  It  appears,  jonma 
facie,  reasonable  to  assume  that  bi-lateral  myosis  in  tabes 
is  owing  to  the  latter  affection ;  and  Remak  sen.  had 
already,  in  1864,  drawn  attention  to  the  occurrence  of 
myosis  in  cervical  tabes.  Disease  of  the  spinal  centre 
for  the  dilatation  of  the  pupil,  or  of  the  fibres  proceed- 
ing from  it,  is  therefore  likely  to  be  at  the  root  of 
paralytic  myosis. 


SYMPTOMS  OF  TABES  SPINALIS.  159 

Hempel,^  who  lias  given  great  attention  to  this  question^ 
believes  that  the  myosis  is  owing  to  paralysis  of  the 
centre  for  pupillary  dilatation  in  the  medulla  oblongata,  and 
that  the  loss  of  the  light-reflex  is  owing  to  an  interrup- 
tion of  the  reflex  arc  between  the  optic  and  the  oculo- 
motor nerve,  the  centre  of  the  latter  being  normal. 

Vincent,    on   the  other  hand,  considers  that  the  reflec- 
tory paths  which  proceed    from  the    optic   nerve  descend 
into  the  cervical  cord,  and  there    undergo    a   fusion  with 
motor    centres,    from   which    again  other     paths    proceed, 
which  stimulate  the  sphincter  of  the  pupil,  to  become  after- 
wards  connected  with  the  trunk  of  the  third  nerve,  and 
thus  to  arrive  at  the  iris.      The  loss  of    the    light-reflex 
would  therefore  be  owing  to  disease  of  certain  centres  and 
paths  which  are  situated  in  the  cervical  portion  of  the  cord. 
Recent    experiments    of   Bechterew     have    shown    that 
the     reflectory     centre    for    the    nerve-fibres    which  con- 
strict   the  pupil  is    situated  in  the   nucleus    of   the  third 
nerve;  for  destruction  of  this  nucleus  as  well  as  division 
of  the  third  nerve,  causes  maximal  dilatation  of  the  corre- 
sponding pupil,  and    complete  immobility  of  the  same  to 
direct    or    indirect    stimulation    by    light.      On    the  other 
hand,  destruction  of  the  optic   tract,  the    corpora  genicu- 
lata     and    quadrigemina,    destroyed    the    function   of   the 
retina,  but  had  no  influence  on  the   mobility  of    the  iris. 
Each    pupil    appears    to    have    an    independent    reflectory 
arch  for  itself  j    the  fibres    which  constrict  it^  proceeding 
from  the  retina  to  the  optic  nerve,  coursing  in  the  latter, 
entering  behind  the  chiasma  immediately  into  the  central 
grey    matter    surrounding    the    cavity    of    the    third    ven- 
tricle, proceeding  thence  to  the  nuclei  of  the  oculo-motor 
nerves,  and  returning  in  the  sheath    of   the  latter  to  the 
periphery.     Commissural  fibres  between  the  nuclei  of  the 
third  pair  connect  the  two  arches,  so  that  the  reflex  may  be 

»  «*  Archiv  fiir  OpMhalmologie,"  vol.  xxii.,  p.  1.     Berlin,  1876. 


160  SCLEROSIS  OF  THE  SPINAL  CORD. 

carried  from  one  eye  to  the  pupil  of  the  other.  When  the 
pupil  is  dilated  in  consequence  of  painful  stimulation, 
this  is  not  owing  to  the  action  of  sympathetic  fibres,  but 
is  caused  independently,  by  inhibition  of  the  light-reflex. 

Reflectory  pupillary  rigidity  would,  therefore,  according 
to  this  be  caused  by  lesions  interrupting  the  path  of  the 
light-reflex  in  its  com'se  from  the  chiasma  to  the  nucleus 
of  the  third  nerve. 

The  presence  of  the  three  symptoms  which  I  have  just 
described,  viz.,  loss  of  knee-jerk,  lightning-pains,  and  re- 
flectory rigidity  of  the  pupil,  render  the  diagnosis  of  tabes 
perfectly  certain,  as  such  a  combination  does  not  occur 
in  any  other  disease.  In  some  cases,  however,  either 
one  or  both  of  these  latter  symptoms  may  be  absent ; 
and  we  have  then  to  look  for  other  evidences  of  the 
malady,  which  I  shall  now  proceed  to  consider. 

4.  Mydriasis  and  Paralysis  of  the  Ciliary  Muscle. — 
Paralytic  mydriasis  constitutes  that  state  of  dilated 
pupil  which  results  from  paralysis  of  the  circular  fibres 
of  the  iris,  while  the  radiating  fibres  of  that  membrane 
remain  intact.  It  is  owing  to  injury  or  disease  involv- 
ing the  third  or  oculo-motor  nerve,  either  in  its  nucleus  or 
in  its  course  towards  the  orbit ;  and  is  generally  seen 
in  certain  diseases  of  the  brain  where  this  nerve  becomes 
implicated,  such  as  meningitis,  hydrocephalus,  etc. ;  or 
it  may  be  a  symptom  of  inflammation  or  sclerosis  of  the 
nerve  itself,  or  of  disease  in  the  short  root  of  the 
ciliary  ganglion.  Mydriasis  is  generally  combined  with 
paralysis  of  the  ciliary  muscle,  causing  loss  of  accom- 
modation ;  and  the  impairment  of  vision  which  results  is 
then  chiefly  owing  to  the  latter. 

Paralytic  mydriasis  may  be  one  of  the  first  symptoms 
of  tabes,  and  precede  the  appearance  of  lightning-pains 
and  other  symptoms  by  several  years.  If  it  comes  on 
suddenly,  and  without  any  apparent  cause,  such  as 
severe  exposure    to   cold,   injury   to    the    eye,  etc.,    it  is 


SYMPTOMS  OF  TABES   SPINALIS.  161 

generally  of  a  syphilitic  nature  ;  and  if  combined  with 
loss  of  the  knee-jerk  may  be  looked  upon  as  foreshadow- 
ing the  outbreak  of  tabes. 

Case  51.  In  October,  1867,  Mr.  White  Cooper  requested 
me    to  see    a    gentleman,  aged  thirty-four,  married,    who 
had  had  syphilis  very  badly  ten  years  ago,   but    had  for 
some  time  past  been  free  from  symptoms  of  it.     Twelve 
months  before  I  saw    him  he  had  been  struck  by  lio-ht- 
ning.      In    January    last,    however,    affection  of    the  iris 
came  on  quite    suddenly,  as    he    found  one    morning    on 
attempting    to    read    that  "all  the    letters    danced  about 
like    Hebrew,"    and    the    right    pupil  was    much  dilated. 
The  degree  of  this  dilatation  varied    at    first,    but    since 
April  last  had  become    stationary.     Calabar   bean    and  a 
variety  of  other    remedial   measures    produced   no    effect. 
When  I  saw  him,  the    pupil  had    an    ovoid    shape,    and 
was  almost,  though  not  quite,  as  much  dilated    as    if    it 
had  been  under  the  influence  of  atropine.     It   was  quite 
immovable,    and    did   not   respond   to  light    or  to    efforts 
of  accommodation.     The  sight  was  considerably  impaired, 
which    was   no  doubt    more  owing  to  the  loss  of  accom- 
modation than  simply  to  the  dilated  pupil. 

This  case  occurred  before  the  days  of  "tendon-reflexes," 
so  that  the  condition  of  the  knee-jerk  was  not  ascertained. 
Ten  years  afterwards,  however,  the  phenomena  of  loco- 
motor ataxy  had  become  fully  developed  in  this  patient. 

5.  Other  Palsies  of  Ocular  Muscles. — One  of  the  com- 
monest symptoms  of  tabes  is  temporary  double  vision,  owing 
to  paresis  or  paralysis  of  the  rectus  externus  or  rectus 
internus  muscles.  Such  double  vision  may  last  only  a 
few  hours  and  then  vanish  and  occur  again  a  few 
months  afterwards.  In  other  cases  it  may  last  for  a  few 
weeks  or  a  month,  then  disappear,  apparently  under  the 
influence  of  treatment,  and  return  again  six  months  after- 
wards, etc.  Some  patients  have  six  or  seven  such  attacks, 
and  eventually  the  palsy  may  become  permanent. 

M 


162  SCLEROSIS  OF  THE  SPINAL  CORD. 

a.  Paralysis  of  the  sixth  nerve  or  ahducens  is  a  very  com- 
mon occurrence  in  tabes,  and  causes  convergent  squint.  The 
degrees  of  this  affection  are  exceedingly  variable,  as  in 
some  cases  it  is  so  slight  that  it  can  only  be  discovered 
by  the  most  careful  examination,  while  in  others  it  is  so 
severe  that  the  eye  cannot  be  moved  outward  beyond  the 
middle  line,  and  the  inward  deviation  of  the  eye  during 
rest  may  be  so  considerable  that  the  cornea  is  entirely  con- 
cealed at  the  inner  angle  of  the  orbit.  In  most  cases 
which  I  have  seen  in  connection  with  tabes,  the  paralysis 
of  the  sixth  nerve  occurred  on  the  left  side. 

Double  vision  then  appears  when  the  object  is  moved 
into  the  left  half  of  the  visual  field,  but  is  absent  in  the 
right  half  ;  and  the  further  the  object  is  moved  to  the 
left,  the  greater  will  be  the  distance  between  the  double 
images.  In  consequence  of  the  confusion  caused  by  the 
double  images,  severe  giddiness  and  even  vomiting  may 
be  caused  ;  and  the  efforts  which  the  patient  makes  in 
order  to  correct  the  diplopia,  by  increasing  the  action  of 
the  superior  rectus  and  inferior  oblique,  often  lead  to  con- 
siderable pain  and  exhaustion.  Duchenne  has  seen  cases 
of  bilateral  affection  of  the  two  sixth  nerves  in  which 
there  was  no  double  vision.  This  affection  may  also  be 
intermittent,  occurring  every  other  day. 

b.  Paralysis  of  the  ocular  muscles  sup2')lied  hy  the  third  or 
oculo-motor  nerve  is  likewise  frequent.  Ptosis  of  the  upper 
eyelid  generally  occurs  together  with  paralysis  of  the 
superior  rectus,  and  may  be  complete,  when  the  eye 
appears  entirely  closed  ;  but  is  more  frequently  incom- 
plete when  the  palpebral  fissure  appears  to  be  more  or  less 
narrowed,  in  exact  proportion  to  the  degree  of  loss  of 
power  in  the  levator  palpebral  superioris  muscle.  Ptosis 
is  generally  a  more  permanent  symptom  than  paralysis  of 
the  rectus  externus,  and  less  likely  to  disappear  without 
some  definite  treatment,  more  especially  an  early  applica- 
tion of  the  continuous  current,  being  undertaken. 


SYMPTOMS  OF  TABES  SPINALIS.  163 

Paralysis  of  the  internal  rectus  causes  divergent  squint ; 
the  eye  is  pulled  outwards  by  the  unrestrained  action  of 
the  external  rectus,  and  cannot  be  moved  beyond  the 
median  line  if  the  paralysis  is  complete.  In  paralysis  of 
the  left  rectus  internus,  the  false  image  is  to  the  patient's 
right,  and  the  distance  between  the  two  images  increases 
the  further  the  object  is  moved  towards  the  right  side. 

Paralysis  of  the  fourth  or  trochlearis  nerve  by  itself  is 
very  rare  in  tabes. 

c.  External  ophthalmoplegia,  or  symmetrical  immobility 
of  all  the  external  ocular  muscles  is  likewise  a  rare  occur- 
rence. This  affection  was  first  described  by  the  founder 
of  modern  ophthalmology,  A.  von  Graefe,^  and  afterwards 
by  Jonathan  Hutchinson.^  The  first  symptom  is  drooping 
of  both  eyelids,  so  as  to  give  the  face  a  sleepy  expression  ; 
and  this  is  soon  followed  by  paresis  or  paralysis  of  all  the 
ocular  muscles,  so  that  the  movements  of  the  eyeball 
are  restricted  or  even  wholly  lost.  The  power  in  the 
muscles  fails  in  groups,  and  not  singly  ;  and  paresis  is 
more  frequent  than  paralysis.  There  is  seldom  complete 
ptosis,  although  the  eyelids  droop  ;  and  impaired  range  of 
the  motion  of  the  eyeballs  is  more  common  than  absolute 
fixation.  In  some  of  these  cases  it  seems  that  there,  is  no 
actual  paralysis,  but  that  the  co-ordination  or  synergy  of 
the  different  groups  of  ocular  muscles  has  been  destroyed. 
A  patient  who  shows  symptoms  of  paralysis  of  the  third 
nerve  on  one  side  when  using  both  eyes,  will  be  able  to 
move  the  affected  eye  and  eyelid  much  better  when  using 
only  that  eye,  and  putting  the  other  for  the  time  being  out 
of  action.  At  a  late  period,  however,  the  paralysis 
may  be  absolute.  The  third,  fourth,  and  sixth  nerves 
are   then   all    involved,    and   the    eyeball   is   then    found 

^"Archiv  fiir  Ophthalmologie,"  vol.   xii.,  pt.  2,  p.  265.     Berlin, 
1866. 

2  "  Medico- Cbirurgical  Transactions,"   vol.  Ixii.,  p.  307.     London, 
1879. 

M  2 


164  SCLEROSIS  OF  THE  SPINAL  CORD. 

to  be  completely  immovable,  and  to  stand  in  the  middle  of 
the  palpebral  fissure,  in  a  forward  direction,  covered  by  the 
drooping  upper  eyelid.  There  are  double  images  in  all 
directions  where  the  paralysis  is  unilateral,  and  where  vision 
is  preserved  in  the  paralysed  eye.  The  pupil  is  moderately 
enlarged,  and  the  accommodation  for  near  things  dimi- 
nished or  lost.  Exophthalmus  is  usually  present.  There 
may  be  diverse  combinations,  so  that  the  third  and  the 
sixth  nerve,  or  the  third  and  the  fourth,  or  the  fourth  on 
one  side,  and  the  sixth  on  the  other  side,  are  paralysed 
together. 

The  mode  of  onset  of  these  combined  palsies  is  only  ex- 
ceptionally acute,  but  mostly  slow,  and  their  evolution  may 
be  accompanied  with  headache,  giddiness,  and  confusion. 
In  some  cases  other  cranial  nerves,  such  as  the  olfactory, 
ihe  optic,  the  motor  portion  of  the  fifth,  the  portio  dura, 
rand  the  pneumogastric  are  likewise  affected.  Von  Graefe 
found  that  some  of  these  cases  occurred  suddenly  in  conse- 
quence of  exposure  to  cold,  while  in  others  it  was  probably 
owing  to  syphilis  ;  and  Hutchinson  discovered  that  some 
patients  suffered  from  locomotor  ataxy.  In  one  of 
them,  where  an  inspection  was  obtained,  degenerative 
atrophy  was  found  in  the  optic,  third,  fourth,  and  sixth 
nerves,  and  the  ganglionic  cells  had  disappeared  from  the 
nuclei  of  all  the  affected  nerves.  The  spinal  cord  could 
not  be  examined,  but  the  symptoms  observed  during  life 
— more  particularly  a  sensation  of  tightness  round  the 
abdomen,  numbness  in  the  hands  and  feet,  incontinence  of 
urine,  obstinate  constipation  of  the  bowels,  and  eventually 
paraplegia — can  leave  no  doubt  whatever  on  the  mind  that, 
had  the  cord  been  examined,  posterior  sclerosis  would  have 
been  discovered.  One  of  Hutchinson's  patients  became 
eventually  insane,  and  another  was  before  death  liable  to 
attacks  of  violent  mental  excitement,  showing  that  tabes 
had  become  complicated  with  general  paralysis  of  the 
insane. 


SYMPTOMS  OF  TABES  SPINALIS.  165 

The  affection  has  therefore  the  greatest  possible  resem- 
blance to  labio-glosso-laryngeal  paralysis,  in  which  there 
is  also  degenerative  atrophy  of  the  ganglionic  cells  of  the 
nerve-nuclei,  on  the  floor  of  the  fourth  ventricle  ;  yet  this 
latter  affection  does  not  occur  in  tabes,  and  appears  gene- 
rally to  have  no  relation  to  syphilis. 

d.  Internal  ophthalmoplegia  is  a  group  of  symptoms 
which  was  first  described  by  Hutchinson,^  and  includes 
according  to  him,  indoplegia,  or  paralysis  of  the  circular 
and  radiating  fibres  of  the  iris,  and  cycloplegia,  or  paralysis 
of  the  ciliary  muscle.  In  iridoplegia  we  have  to  do  with 
total  paralysis  of  the  iris,  of  its  circular  or  contracting  as 
well  of  its  radiating  or  dilator  fibres,  causing  the  pupil 
to  be  perfectly  motionless,  so  that  it  is  quite  insensible  to 
the  stimulus  of  light,  and  can  neither  be  contracted  nor 
dilated.  In  cycloplegia,  on  the  other  hand,  we  have  total  loss 
of  the  power  of  accommodation,  so  that  young  and  middle- 
aged  persons  require  strong  convex  glasses  for  reading. 
This  latter  occurs  by  itself  only  after  diphtheria,  but  in  all 
other  conditions  appears  to  be  combined  with  iridoplegia. 
Syphihs  appears  to  be  the  only  cause  which  could  be 
discovered  in  Hutchinson's  cases.  This  able  observer 
does  not  mention  that  any  of  his  patients  were  likewise 
suffering  from  tabes ;  yet  there  can  be  no  doubt  from  his 
description  of  some  of  their  symptoms  that  at  least  some  of 
them  were  affected  with  that  disease.  Thus  it  is  men- 
tioned that  one  patient  had  suffered  severely  from  sciatica, 
which  may  have  been  "  lightning-pains  ;  "  another  was 
subject  to  "rheumatic  achings  in  the  limbs,"  and  liable  to  a 
nervous  cough,  which  sometimes  produced  vomiting,  had 
had  severe  sick  headaches,  and  an  attack  of  most  violent 
neuralgia  in  the  face,  lasting  a  few  days  ;  a  third  had 
complained  of  occasional  stabbing  pains  in  the  lower 
limbs,  chiefly  at  night,  and  of  constipation  and  flatulence. 

'**  Medico -Chirurgical  Transactions,"  -vol.  Ixxi.,  p.  215.     London, 
1878. 


166  SCLEROSIS  OF  THE  SPINAL  CORD. 

An  examination  of  the  knee-jerk  should  never  be  omitted 
in  any  future  examination  of  such  cases,  and  would  at 
once  settle  this  question,  which  is  as  yet  undecided. 

Hutchinson  is  of  opinion  that  this  group  of  symptoms 
is  due  to  disease  of  the  lenticular  or  ophthalmic  ganglion, 
which  supplies  the  iris  and  the  ciliary  muscle,  and  that  when 
this  triad  of  symptoms  is  present,  and  there  are  no  others, 
the  seat  of  the  disease  can  be  in  no  other  structure  than 
the  ganglion  itself.  It  is,  however,  to  be  noted  that  in 
one  of  his  cases  (No.  5)  the  superior,  inferior,  and  internal 
recti  were  weakened,  while  in  another  (No.  8)  all  the 
ocular  muscles  were  paralysed.  This  state  of  things  would 
at  once  carry  the  seat  of  the  disease  further  backwards  to 
a  more  central  point,  viz.,  the  nucleus  of  the  third  nerve. 
Moreover  in  all  these  cases  a  specific  treatment  was  insti- 
tuted which,  although  it  did  not  cure  the  symptoms  which 
were  present,  yet  may  have  prevented  the  disease  from 
extending  further  in  the  nucleus  of  the  third  nerve.  It  is 
also  difficult  to  explain,  on  the  theory  that  the  disease  is 
in  the  lenticular  ganglion,  why  the  iridoplegia  should  pre- 
cede the  loss  of  accommodation,  and  why  the  ciliary 
muscle  and  the  sphincter  of  the  pupil  should  suffer  in 
different  degrees  ;  while  this  would  be  easily  accounted  for  if 
we  assume  the  seat  of  the  disease  to  be  in  the  nucleus  of  the 
third  nerve.  Another  objection  to  Hutchinson's  theory  of 
the  lenticular  ganglion  being  in  fault  is  that  in  the  majority 
of  his  cases  both  eyes  should  have  been  affected,  for  it  must 
appear  highly  improbable  that  there  should  be  simultaneous 
disease  of  both  lenticular  gauglia,  which  are  so  far  apart 
anatomically  ;  and  it  would  seem  to  be  much  more  in  conson- 
ance with  general  pathological  principles  to  assume  that  the 
disease  is  situated  more  centrally,  and  at  a  part  where  the 
centres  for  the  muscles  of  the  eye  are  close  together. 

In    this    respect   recent    researches     by    Hensen    and 
Voelckerfi  are  of  considerable  interest.     They  found  that 

^  Erlenmeyer's  "  Centralblatt  fiir  Neurologie,"  February,  1881. 


SYMPTOMS  OF  TABES  SPINALIS. 


167 


there  is  in  the  dog  a  nuclear  area  in  the  posterior 
portion  of  the  floor  of  the  third  ventricle  and  the  aque- 
duct of  Sylvius,  which  has  definite  relations  to  all  the 
movements  of  the  eyes.  Stimulation  of  that  portion  of  the 
area  which  is  most  in  front,  showed  it  to  be  connected 
with  the  cihary  muscle  for  accommodation  ;  the  one  next 
behind  with  the  iris  ;  that  portion  which  is  between  the 
third  ventricle  and  the  aqueduct,  with  the  rectus  internus  ; 
while  still  further  behind  were  found  the  centres  for  the 
rectus  superior,  the  levator  palpebrae,  the  rectus  inferior  ; 
and  most  backward  that  for  the  obliquus  inferior. 

This    arrangement  of  the  nuclei  of  the  third  nerve  is 
most  probably  the  same  in  man  ;    for  Kahler  and  Pick 
have  found  in  two  cases  in  which  the  function  of  the  iris 
and  accommodation  had  been  normal,  that  the  anterior  por- 
tion of  the  area  just  described  was  healthy  ;  while  in  one 
of  these  where  there  had  been  paralysis  of  the  rectus  in- 
ternus, the  median  part  of  the  area  was  destroyed,  and  in 
another,  where  the  rectus   superior,  the  obliquus  inferior, 
and  the  levator  palpebrae  had  been  paralysed,  the  posterior 
portion  of  the  area  was  found  sclerosed.     This   arrange- 
ment likewise  accounts  easily  for  the  independent  afiection 
of  the  rectus  internus,  which  has  been  occasionally  observed, 
as  there  is  a  separate  nuclear  area  for  this  muscle. 

6.  Olfactory  derangements. — Anosmia,  or  loss  of  smell  may 
occur  from  congenital  absence  of  the  olfactory  nerve  ; 
and  is  not  infrequent  in  the  aged,  where  sclerosis  of 
the  nerve  is  sometimes  discovered  after  death,  affecting 
chiefly  the  external  root,  which  may  be  traced  to  the 
fissure  of  Sylvius,  and  which  seems  to  be  more  impor- 
tant for  olfaction  than  the  middle  or  internal  root.  In  tabes 
anosmia  may  be  owing  to  acute  inflammation  of  the 
olfactory  nerve,  but  occasionally  it  comes  on  more  slowly, 
and  is  then  no  doubt  owing  to  chronic  degenerative 
atrophy  of  the  same.. 

Case  62.— In  October,  1878,  a  banker's  clerk,   aged  48 


168  SCLEROSIS  OF  THE  SPINAL  CORD. 

married  and  father  of  two  children,  was  admitted  into 
the  hospital  under  my  care.  He  had  been  in  tolerably 
good  health  until  about  eight  years  ago,  when,  apparently 
without  any  particular  cause,  he  suddenly  began  to  feel 
numbness  in  his  feet,  and  lost  the  proper  perception  of 
the  hardness  of  the  ground.  It  seemed  to  him  as  if  he 
was  treading  on  india-rubber  balls,  or  bales  of  cotton. 
About  the  same  time  he  was  startled  by  perceiving  a 
strong  smell  of  phosphorus,  which  overpowered  all  other 
accidental  smells,  and  never  left  him  at  all  for  about  six 
weeks.  At  the  end  of  that  period  he  noticed  that  he  had 
entirely  lost  the  sense  of  smell  for  odoriferous  substances 
of  any  description.  The  smell  of  phosphorus  had  then 
given  way  to  a  persistent  and  not  unpleasant  kind  of  scent- 
sensation,  which  he  compared  to  that  of  civet,  very  much 
softened  down.  This  sensation  continued  for  several 
years,  but  was  now  likewise  gone ;  and  there  was  at 
present  a  total  absence  of  olfactory  sensibility.  I  tested 
the  patient  with  assafoetida,  ether,  valerian,  camphor,  mille- 
fleurs,  opoponax,  and  a  variety  of  other  strongly-smelling 
substances,  either  pleasant  or  disagreeable,  none  of  which, 
however,  produced  the  slightest  effect  upon  his  nose.  He 
did  perceive  ammonia,  which  caused  lachrymation  and  a 
choking  sensation,  just  as  in  healthy  persons,  and  also  the 
vapour  of  strong  acetic  acid,  and  snuff,  which  caused 
sneezing.  All  these  last-named  substances,  however,  act 
chiefly  on  the  nerves  of  common  sensation,  viz.,  the  nasal 
twigs  of  the  ophthalmic  branch  of  the  fifth  nerve,  and  the 
spheno-palatine  ganglion,  which  were  in  their  normal 
condition. 

The  perception  of  flavours  in  eating  and  drinking  was 
likewise  almost  entirely  gone.  It  is  well  known  that 
the  gustatory  nerve  only  responds  to  four  different  kinds 
of  sapid  substances,  viz.,  the  saline,  the  acid,  the  bitter 
and  the  sweet ;  and  that  flavours  are  recognized  by  the 
olfactory,  not  by  the  gustatory  nerve.     In  accordance  with 


SYMPTOMS  OP  TABES  SPINALIS.  169 

this  I  found  that  when  the  patient's  eyes  were  bandaged  so 
that  he  could  not  see  what  he  was  eating  or  drinking,  he 
was  unable  to  distinguish  between  stewed  onions,  apples, 
and  turnips  ;  although  he  could  tell  roast  beef  from  roast 
mutton.  He  did  not  perceive  the  flavour  of  port  wine  or 
claret,  but  felt  the  former  hotter  than  the  latter,  saying  it 
was  gin  or  hrandy,  while  claret  appeared  to  him  like 
vinegar  and  water.  These  sensations  were  evidently 
owing  to  impressions  made  on  the  lingual  and  palatine 
branches  of  the  fifth  nerve,  and  partook  of  common  sensa- 
tion rather  than  of  special  sense.  It  is  a  singular  fact 
that,  until  experimented  upon  in  this  manner,  the  patient 
was  not  aware  that  he  had  lost  the  perception  of  flavours, 
but  thought  that  he  tasted  everything  quite  as  well  as 
previously  to  having  lost  his  smell — vision  and  memory 
evidently  supplying  in  this  instance  the  lost  sense.  Besides 
anosmia,  symptoms  of  tabes  existed  in  the  upper  and  lower 
extremities,  the  bladder,  rectum,  and  sexual  organs,  and 
the  patient  offered  one  of  the  most  perfect  types  of  sclerosis 
of  the  posterior  columns  of  the  spinal  cord  that  could  well 
be  found. 

In  this  case  the  anosmia  was  evidently  not  owing  to  any 
affection  of  the  accessory  mechanism  of  smell,  such  as 
inflammation  of  the  Schneiderian  membrane,  oz^na,  poly- 
pus, adhesion  of  the  soft  palate  to  the  posterior  wall  of  the 
pharynx,  paralysis  of  the  portio  dura,  etc.  ;  for  the  entire 
accessory  mechanism  of  that  sense  was  found  to  be  in  per- 
fect order.  Nor  could  it  be  attributed  to  disease  of  the 
olfactory  centre  in  the  brain,  which  Ferrier  has  shown  to 
reside  in  the  subiculum  cornu  ammonis.  If  there  had  been 
a  lesion  extensive  enough  to  destroy  both  subicula,  surely 
other  symptoms,  and  more  particularly  entire  loss  of 
taste,  must  have  been  present.  In  their  absence  it  seemed 
permitted  to  assume  that  the  lesion  was  a  peripheral  one, 
and  was  seated  where  the  olfactory  ganglia  lie  closely 
together,  at  the  base  of  the  brain,  on  the  cribriform  plate 


170  SCLEROSIS  OF  THE  SPINAL  CORD. 

of  the  ethmoid  bone.  The  clinical  signs  showed  at  first  a 
stage  of  sensory  hyper^esthesia  which  lasted  for  six  weeks, 
and  then  merged  into  complete  anaesthesia.  This  corres- 
ponds closely  to  what  I  have  observed  in  neuritis  of  the 
fifth  nerve,  where  there  is  likewise  a  stage  of  hypersesthesia, 
as  evidenced  by  severe  pains  in  the  parts  supplied  by  that 
nerve,  and  lasting  for  five  or  six  weeks,  after  which  com- 
plete anaesthesia  of  the  face  and  scalp,  and  paralysis  of  the 
niuscles  of  mastication,  which  are  supplied  by  the  small 
root  of  the  nerve,  set  in. 

Why  should  this  patient  have  perceived  a  phosphorous 
smell  during  the  first  period  of  his  illness  ?  I  believe  I 
am  in  a  position  to  affirm  that  the  olfactory  nerve  responds 
to  stimulation  other  than  by  special  odoriferous  substances, 
by  perception  of  the  smell  of  phosphorus.  It  is  well 
known  that  the  constant  voltaic  current  has  a  peculiar 
action  on  the  nerves  of  special  sense,  which  answer  to 
its  passage  by  certain  well-marked  sensations.  Thus, 
galvanisation  of  the  optic  nerve  causes  flashes  of  light,  of 
the  gustatory  nerve  a  coppery  taste  in  the  mouth,  of  the 
auditory  nerve  a  singing  or  hissing  noise  in  the  ear.  It  is 
easy  to  demonstrate  these  facts,  because  the  nerves  I  have 
just  mentioned  are  very  sensitive  to  the  influence  of  the 
voltaic  current,  and  therefore  respond  to  a  slight  power  ; 
while  the  olfactory  will  only  give  an  answer  when  a  very 
high  power  is  used.  A  very  powerful  voltaic  current, 
however,  when  applied  to  the  nose  or  any  other  part  of 
the  face,  causes  such  disagreeable  sensations  of  pain,  giddi- 
ness, sickness,  together  with  dazzling  flashes  of  light  and 
loud  noises  in  the  head,  that  experimenters  in  general 
have  been  unwilling  to  bear  the  inconvenience  of  the  pro- 
cedure, or  unable  to  analyse  all  the  various  sensations  per- 
ceived at  the  time.  The  fact,  therefore,  that  the  olfactory 
nerve  does  respond  to  the  voltaic  current  by  the  perception 
of  a  phosphorous  smell  was  not  established  until  some  years 
ago,  when  I  demonstrated  it  in  a  patient  who  suffered  from 


SYMPTOMS  OF  TABES  SPINALIS.  171 

bilateral  angesthesia  of  the  fifth  pair  of  cerebral  nerves.^  In 
that  case  a  strong  voltaic  current  could  be  borne  without 
inconvenience,  because  the  patient  was  insensible  to  a 
moderate  power.  The  patient  was  in  perfect  health, 
except  as  far  as  the  affection  of  the  fifth  nerve  was  con- 
cerned. His  smell  was  keen  ;  and  when  a  powerful  cur- 
rent was  directed  to  the  mucous  membrane  of  the  nose, 
which  was  insensible  to  ordinary  stimulation,  the  patient 
invariably,  and  without  being  questioned  about  it,  said,  "  I 
smell  phosphorus " ;  just  as  he  mentioned  that  he  saw 
flashes  of  light  when  the  current  was  directed  to  his  eyes. 
It  is  fair  to  assume  that  irritation  of  the  olfactory  nerve  by 
hypersemia  and  inflammation  will  likewise  cause  a  smell  of 
phosphorus,  such  as  I  have  shown  to  follow  voltaic  irrita- 
tion of  the  nerve,  and  just  as  in  retinitis  flashes  of  light  are 
perceived  by  the  patient.  All  these  circumstances  taken 
together  appear  to  me  to  warrant  the  conclusion  at  which 
I  have  arrived,  that  the  case  just  related  was  one  of  acute 
olfactory  neuritis,  ushered  in  by  hypergesthesia,  and  marked 
in  its  later  stage  by  anaesthesia  of  that  special  sense. 

The  patient  died  of  collapse  some  months  after  admis- 
sion, and  Dr.  Ferrier,  who  was  then  my  colleague  at  the 
hospital,  made  the  autopsy.  Sclerosis  of  the  posterior 
columns  of  the  cord,  with  some  spinal  meningitis,  was  dis- 
covered, and  on  opening  the  skull,  the  naked-eye  appear- 
ances of  neuritis  of  the  first  pair  at  the  base  of  the  brain 
were  seen.  The  specimens  were  removed,  and  handed  for 
microscopic  examination  to  the  late  Dr.  Lockhart  Clarke, 
who  was  then  likewise  physician  to  the  hospital.  Unfor- 
tunately, that  gentleman  died  soon  afterwards,  and  I  have 
not  been  able  to  trace  the  specimens,  which  is  much  to  be 
regretted  in  a  case  so  unusual.^ 

'  Vide  my  paper,  **  On  the  Physiology  and  Pathology  of  the  Fifth 
Pair  of  Cerehral Nerves,"  in  •'Transactions  of  the  Eoyal  Medical  and 
Chirurgical  Society,"  vol.  lii.,  p.  27.     London,  1869. 

2  Vide  my  Paper,  "  On  Neuritis  and  Peri-neuritis  of  some  of  the 


172  SCLEROSIS  OF  THE  SPINAL  CORD. 

Occasionally,  anosmia  is  evanescent,  like  palsies  of  the 
rectus  externus  or  interuns  muscles.  If  it  comes  on  without 
any  apparent  cause,  such  as  injury  to,  or  over-stimulation 
of,  the  olfactory  nerve,  etc.,  it  is  a  suspicious  symptom  ; 
and  an  examination  of  the  knee-jerk  should  on  no  account 
be  neglected. 

Hyperosmia  also  occurs  occasionally  in  tabes,  and  shows 
this  peculiarity,  that  only  unpleasant  smells  are  perceived. 
There  is  never  an  impression  of  nice  scents  or  sweet- 
smelling  flowers,  but  rather  that  of  rotten  eggs,  or  any 
other  kind  of  abomination,  faecal  matters,  burning  sulphur^ 
or  phosphorus.  A  similar  hyperaesthesia  of  taste  may  be 
observed,  so  that  everything  that  is  eaten  has  a  horrible  or 
sickening  flavour,  as  of  mud  or  faeces,  and  nothing  ever 
tastes  "  nice."  These  forms  of  hyperaesthesia  are  often 
premonitory  symptoms  of  certain  forms  of  mental  derange- 
ment which  are  apt  to  occur  in  the  tabid,  and  which  will 
be  subsequently  considered. 

7.  Amblyopia  and  Amaurosis. — Tabes  is  frequently 
accompanied  by  atrophy  of  the  optic  nerves,  the  anatomi- 
cal characters  of  which  have  abeady  been  described  (p. 
26).  The  most  important  information  on  this  condition 
is  that  which  is  furnished  by  ophthalmoscopic  examina- 
tion ;  yet  it  should  not  be  forgotten  that  in  the  beginning 
of  the  malady  the  optic  disc  does  not  show  any  patho- 
logical alteration,  and  that  the  amblyopia  of  tabes  may, 
therefore,  at  that  stage  be  confounded  with  that  occurring 
in  diabetes  and  chronic  alcoholism.  From  these  latter  the 
optic  atrophy  of  tabes  may,  however,  be  distinguished  by 
its  always  commencing  in  one  eye,  and  by  one  eye  being, 
in  the  further  course  of  the  disease,  always  worse  (or 
better)  than  the  other,  except  where  the  patient  has  be- 


Cranial  Nerves,"  in'^"  Brain,"  part  v.,  p.  10,  April,  1879,  and  my  Lec- 
ture, **  On  the  Physiology  and  Pathology  of  the  Olfactory  Nerve,"  in 
"  The  Lancet,"  May  21,  1881. 


SYMPTOMS  OF  TABES  SPINALIS.  173 

come  stone-blind,  while  in  diabetes  and  alcoholism  optic 
atrophy  is  at  once  bilateral.  Wasting  of  the  fibres  of  the 
optic  nerve  is  accompanied  by  shrinking  of  their  capillary 
vessels.  The  optic  disc,  therefore,  appears  pale  and  whitish ; 
when  examined  by  the  ophthalmoscope,  a  grey  colour  is 
mino-led  with  the  pink,  and  as  the  atrophy  becomes  more 
marked,  eventually  a  peculiar  glistening  bluish  or  greenish 
mottled  or  mother-of-pearl  tint  is  seen.  At  the  same  time 
the  edges  of  the  disc  appear  sharply  defined,  showing  a  dis- 
tinct line  of  demarcation  from  the  neighbouring  parts  ;  and 
to  this  is  added  a  more  or  less  considerable  degree  of 
excavation,  from  the  surface  of  the  disc  being  depressed. 
This  is  found  to  be  in  exact  proportion  to  the  degree  of 
atrophy  which  may  be  present.  Where  there  is  much 
wasting  of  nerve-tubes  and  only  little  overgrowth  of  neuro- 
glia, the  excavation  is,  therefore,  much  more  marked  than 
where  the  connective  tissue  is  much  increased.  In  some 
cases,  indeed,  the  nerve,  although  profoundly  altered  in  its 
structure,  is  very  slightly  reduced  in  size,  with  the  result 
that  the  excavation  is  minimal.  The  arteries  of  the  retina 
are  generally  small  and  attenuated,  resembling  thin  threads, 
but  this  is  not  invariable,  as  in  some  cases  the  vessels  seem 
to  retain  their  normal  calibre.  The  small  vessels  on  the 
disc  are  wasted,  or  have  altogether  disappeared.  The  veins 
of  the  retina  may  appear  quite  normal,  and  if  reduced  in 
size,  they  are  less  so  than  the  arteries. 

From  this  description  it  will  be  seen  that  the  ophthal- 
moscopic appearances  in  the  optic  atrophy  of  tabes  are 
entirely  different  from  those  of  optic  neuritis,  as  habitually 
seen  in  cases  of  intracranial  tumour,  and  where  atrophy 
may  eventually  follow  the  inflammation.  In  the  latter 
case  there  are  always  traces  of  effusion  about  the  disc, 
the  edges  of  which  are  not  sharply  cut,  but  blurred  ;  and 
a  somewhat  indistinct  zone  of  transition  is  seen  between 
it  and  the  fundus  of  the  eye.  The  arteries  are  reduced 
in  size,    and    the    veins  tortuous    and    dilated.      Another 


174  SCLEROSIS  OF  THE  SPINAL  CORD. 

difference  between  optic  atrophy  and  optic  neuritis  is, 
that  the  former  invariably  commences  in  one  eye,  and 
that  the  other  eye  begins  to  suffer  a  few  months  after- 
wards, while  optic  neuritis  is  at  once  bilateral. 

The  mode  of  evolution  of  optic  atrophy  is  in  general 
slow  and  continuously  progressive.  There  may  in  the 
beginning  be  headache,  pains  in  the  eye,  and  subjective 
luminous  appearances  denoting  a  degree  of  hypersesthesia 
of  the  optic  nerve  ;  the  patient  then  sees  sparks  of  dif- 
ferent colours,  fireworks,  or  insects  floating  before  his  eyes, 
and  may  have  the  sensation  of  a  foreign  body,  such  as  dust 
or  small  bits  of  coal  in  the  eyes  ;  or  there  may  be  hemi- 
anaesthesia  of  the  face.  At  the  same  time  vision  becomes 
indistinct,  and  the  objects  appear  veiled,  or  as  in  a  fog. 
This  latter  symptom,  however,  may  also  occur  from  loss 
of  accommodation  by  paralysis  of  the  ciliary  muscle.  A 
more  definite  sign  of  commencing  amaurosis  is  a  restric- 
tion or  contraction  of  the  field  of  vision,  which  usually  com- 
mences at  the  temporal  side,  and  only  very  rarely  on  the 
nasal  side.  This  contraction  after  a  time  proceeds  either 
laterally  towards  the  centre  of  the  visual  field,  or  it  creeps 
along  its  periphery  both  upwards  and  downwards  until  it 
reaches  the  opposite  side  ;  and  only  after  the  whole  peri- 
phery has  been  invaded,  the  contraction  advances  towards 
the  centre.  It  affects  first  one  eye,  and  after  a  variable 
interval  the  other,  where  it  often  takes  exactly  the  same 
course  as  in  the  one  first  affected.  According  to  G-ale- 
zowski,  it  is  characteristic  for  the  syphilitic  form  of  amau- 
rosis, that  the  contraction  of  the  visual  field  first  invades 
the  entire  periphery,  and  only  then  advances  towards  the 
centre.  I  have,  however,  seen  a  case  (p.  106)  where  the 
affection  was  undoubtedly  owing  to  syphilis,  and  where  the 
patient  stated  that  a  dark  cloud  seemed  to  have  become 
settled  at  the  top  of  the  field  of  vision  in  the  right  eye, 
and  that  he  was  unable  to  distinguish  with  that  eye  any- 
thing above  the  eyebrow.     On  the  other  hand.  Hardy  has 


SYMPTOMS  OF  TABES  SPINALIS.  175 

seen  a  case  where  the  lower  halves  of  the  visual  field  in 
both  ejes  were  blind,  so  that  the  patient  could  only  dis- 
tinguish the  upper  halves  of  objects.  This  affection, 
however,  was  transitory,  like  palsies  of  ocular  muscles, 
and  disappeared  at  the  end  of  a  fortnight.  These  two 
cases  however,  show  that  Galezowski's  statement  does  not 
invariably  apply. 

Another  important  symptom  is  presently  added  in  the 
shape  of  scotomata,  or  breaks  in  the  continuity  of  the 
visual  field,  causing  the  patient  to  sfee  dark  irregular  spots 
before  his  eyes.  The  degree  to  which  these  scotomata 
interfere  with  vision,  depends  upon  their  situation,  and  is 
particularly  great  if  they  sit  in  the  visual  axis,  while  it  is 
much  less  where  they  invade  the  periphery. 

Colour-blindness  (Daltonism,  dyschromatopsia,  achroma- 
topsia) is  also  very  common  at  this  stage.  The  patient  is 
unable  to  distinguish  red  and  green,  both  of  them  appear- 
ing grey  or  black,  or  of  a  dirty  brown  colour,  while 
blue  and  yellow  may  be  readily  recognised.  After  a 
time  the  colour-blindness  becomes  complete,  and  the 
patient  can  only  distinguish  between  white  and  black. 
Dislike  to  bright  light  is  also  common. 

Unless  an  energetic  specific  treatment  is  instituted  at 
the  very  beginning  of  these  troubles,  the  course  of  the 
affection  is  progressive  and  ends  in  complete  blindness. 
The  time  which  elapses  between  the  first  beginning  of 
the  amblyopia  and  the  total  amaurosis,  varies  ordinarily 
from  one  to  six  years.  I  have  now  a  patient  under  my  care 
in  whom  the  right  eye  began  to  show  symptoms  of  atrophy 
of  the  optic  nerve  in  1872.  Mercury  and  iodide  of  potas- 
sium were  then  given,  under  the  influence  of  which  the 
affection  became  stationary  in  the  right  eye,  and  has  up  to 
this  time  (May,  1884)  spared  the  left,  although  some  other 
symptoms  of  tabes  have  since  then  become  developed. 

Optic  atrophy  is  not  nearly  as  frequent  as  Argyll- 
Robertson's    symptom,    or    palsies    of     individual    ocular 


176  SCLEROSIS  OF  THE  SPINAL  COKD. 

muscles.  It  seems  to  occur  in  one  case  out  of  about  ten 
or  twelve,  and  may  be  one  of  one  first  symptoms  of  the 
disease,  or  is  only  developed  in  the  later  stages  of  it.  I 
have  found  it  to  be  invariably  combined  with  loss  of  the 
knee-jerk  in  the  very  beginning,  and  these  two  symptoms 
may  be  the  only  signs  of  tabes  for  years.  Sooner  or  later, 
however,  other  symptoms  of  the  principal  malady  super- 
vene ;  and  in  La  Salpetriere  Charcot  has  noticed  that  most 
women  who  are  admitted  into  that  infirmary  with  optic 
atrophy  become  tabid*after  a  longer  or  shorter  space  of 
time.  Spinal  myosis  is  frequently  combined  with  the  optic 
atrophy  of  tabes,  while  in  other  forms  of  this  atrophy  the 
pupil  is  generally  enlarged. 

8.  Derangements  of  the  Auditory  Nerve. — I  have  already 
mentioned  that  of  the  two  portions  of  the  auditory  nerve, 
the  nerve  of  space,  or  vestibulary  nerve,  suffers  more  fre- 
quently in  tabes  than  the  cochleary  or  true  auditory  nerve. 
Occasionally,  however,  both  portions  of  this  nerve  are 
affected  together  : — 

Case  53. — A  butcher,  aged  32,  married,  and  father  of 
three  children,  was  admitted  into  the  hospital  under  my 
care  in  January,  1876.  He  had  been  in  good  health  until 
the  commencement  of  1875,  when  he  began  to  feel  poorly, 
and  suffered  from  a  troublesome  form  of  indigestion,  with 
nausea  and  loss  of  appetite  (gastric  crises  ?).  In  May  of 
the  same  year  he  suddenly  began  to  squint  and  see  things 
double,  evidently  from  paralysis  of  one  of  the  ocular 
muscles,  although  it  would  be  impossible  to  determine  at 
present  which  one  of  them  was  affected.  These  latter 
symptoms  lasted  only  for  a  few  days  and  then  left  him  ; 
but  shortly  afterwards  he  was  affected  with  vertigo  and 
a  roaring  noise  in  the  head.  There  was  also  a  feeling  of 
sickness,  but  no  vomiting.  Within  a  few  days  the  tinnitus 
increased  considerably,  and  appeared  to  him  like  thunder, 
or  as  if  there  were  explosions  of  gunpowder  in  his  head  ; 
at  other  times  it  resembled  the  ringing  of  bells  and  scream- 


SYMPTOMS  OF  TABES  SPINALIS.  177 

ing  of  whistles.  There  was  at  no  time  any  loss  of  con- 
sciousness. This  severe  form  of  tinnitus  lasted  for  rather 
more  than  a  month,  during  which  time  the  hearing  of  the 
patient,  which  before  then  had  been  perfectly  good,  was 
gradually  much  diminished,  and  at  the  end  of  the  period 
mentioned  he  found  himself  stone-deaf.  By  this  time  the 
vertigo  had  left  him,  but,  on  going  about,  he  noticed  that 
he  did  not  walk  as  well  as  before,  more  particularly  in  the 
dark,  and  was  apt  to  stumble,  especially  on  turning  round  ; 
and  he  felt  the  peculiar  sensation  as  if  walking  on  cotton 
or  bladders.  Pain  of  a  character  peculiar  to  tabes  began 
to  shoot  through  the  lower  extremities,  more  especially  in 
the  night  and  on  exposure  to  wet  or  cold.  The  ataxy  in- 
creased rapidly,  in  spite  of  medical  treatment,  so  that  he 
became  completely  helpless  ;  and  when  he  entered  the 
hospital,  he  had  already  reached  the  third  stage  of  the 
disease,  in  which  not  only  the  co-ordination  of  movements 
but  also  muscular  power  suffers. 

The  examination  of  the  patient  proved  unusually  trouble- 
some, as  he  was  stone-deaf,  and  all  questions  had  therefore 
to  be  written  down  for  him  on  a  slate.  He  was  found  to  be 
utterly  insensible  to  the  shrillest  and  loudest  noise,  such  as 
that  of  a  cab- whistle  blo^ii  just  behind  him,  as  well  as  to 
the  sounds  of  musical  instruments.  He  could  not  hear  a 
watch  tick  when  it  was  applied  to  the  external  ears  or  the 
cranial  bones  around  ;  nor  did  he  perceive  the  sound  of  a 
tuning-fork  applied  to  the  vertex  and  to  the  teeth.  On 
applying  the  constant  voltaic  current  to  the  ears,  however, 
a  distinct  sound  was  perceived  on  making  with  the  cathode 
and  breaking  with  the  anode.  This  sound  the  patient 
likened  to  a  "  blowing "  or  "  ringing "  noise,  and  it  ap- 
peared to  continue  for  some  seconds  after  the  current  had 
commenced  and  ceased  to  act.  This  was  over  and  above 
the  habitual  tinnitus,  which  never  left  the  patient,  and 
which  was  now  of  a  moderate  kind,  resembling  the  flowing 
of  water.     The  patient  spoke  intelligibly,  and  although  he 

N 


178  SCLEROSIS  OF  THE  SPINAL  CORD. 

could  not  hear  himself  speak,  he  had  no  deficient  or  altered 
intonation  of  the  voice. 

The  physiognomical  expression  was  peculiar.  His 
features  appeared  in  perfect  repose,  and  unimpressionable, 
except  when  a  question  in  writing  was  put  to  him.  Having 
noticed  a  similarly  statuesque  expression  in  a  case  of 
anaesthesia  of  the  fifth  nerve,  from  loss  of  cutaneous  and 
muscular  sensibility,  I  carefully  tested  the  sensibility  all 
over  the  face,  but  found  it  perfectly  normal  ;  and  the  total 
absence  of  physiognomical  expression  was  therefore  in  this 
instance  owing  to  the  patient  being  as  it  were  shut  out 
from  the  world,  and  being  indifferent  to  what  went  on 
around  him. 

I  may  here  remark  that  some  time  later  I  had  the 
advantage  of  Mr.  Dalby's  opinion  on  the  state  of  the 
patient's  ears.  He  confirmed  my  diagnosis  of  the  nervous 
origin  of  the  deafness,  as  he  found  the  external  and  middle 
ear,  including  the  Eustachian  tube  and  the  tympanum,  per- 
fectly healthy.  The  conduction  of  sound  was  good,  but 
the  perception  of  it  absent,  and  he  therefore  thought  the 
deafness  due  to  change  in  the  nervous  structures,  either 
in  the  labyrinth  or  intra-cranial. 

The  patient  had  not  inherited  any  tendency  to  nervous 
affections  such  as  paralysis,  insanity,  or  neuralgia.  He 
had  always  been  a  steady,  hard-working  man,  not  given  to 
alcoholic  or  venereal  excesses.  He  had  never  had  syphilis 
or  gonorrhoea.  He  never  smoked.  He  had,  however,  in 
his  trade,  as  a  butcher,  been  obliged  to  go  about  a  great 
deal  in  all  kinds  of  weather,  and  in  the  small  hours  of  the 
morning,  and  had  lately  had  much  anxiety  about  money 
matters. 

There  were  no  symptoms  indicating  cerebral  disease  ;  the 
intellect,  memory,  and  speech  being  quite  normal,  and  all 
the  cerebral  nerves,  with  the  only  exception  of  the 
auditory,  were  in  full  functional  activity. 

The  spine  was  not  tender  to  pressure  or  percussion,  nor 


SYMPTOMS  OF  TABES  SPINALIS.  179 

was  there  any  spontaneous  pain  in  it ;  and  the  pain  in  the 
limbs  was  less  marked  than  it  had  been  some  time  ago. 
There  was  incomplete  cutaneous  anaesthesia  from  the  waist 
downwards  to  the  feet,  and  also  incomplete  muscular 
anaesthesia.  Tickling  the  soles  produced  no  reflex  move- 
ments, and  pinching  the  gastrocnemius  and  rectus  femoris 
produced  hardly  any  sensation.  The  muscles  were  flabby 
and  somewhat  wasted,  but  responded  freely  to  the  voltaic 
and  faradic  currents.  The  patient  could  not  walk  at  all, 
except  when  supported  by  two  persons,  and  even  then  he 
had  the  greatest  difficulty  in  stepping  out,  the  peculiar 
jerking  gait  of  ataxy  being  perfectly  discernible.  The  help- 
lessness was  so  great  that  it  verged  on  paralysis.  He  could 
only  stand  when  supported  by  two  sticks,  and  when  he 
closed  his  eyes  he  reeled  like  a  drunken  man.  Yet  he 
could,  when  lying  down  or  sitting  on  a  chair,  move  his  legs 
and  feet  tolerably  well. 

The  sexual  power  had  been  gradually  lost  during  the 
last  six  months,  and  the  bladder  and  rectum  likewise 
participated  in  the  disease.  There  was  great  difficulty  in 
passing  water,  the  patient  having  to  strain  for  fifteen  or 
twenty  minutes  before  he  succeeded  in  voiding  a  few 
ounces  of  urine.  Occasionally  there  was  incontinence. 
The  urine  was  habitually  neutral,  and  contained  a  large 
excess  of  urea  and  phosphates,  but  no  albumen  or  sugar. 
The  bowels  were  confined,  and  when  purgatives  were  ad- 
ministered they  often  acted  so  rapidly  that  the  faeces  were 
voided  before  the  patient  had  time  to  reach  the  commode. 

The  upper  extremities  were  unaSected,  with  the  excep- 
tion of  a  slight  feeling  of  numbness  in  the  third  and  little 
finger  of  the  left  hand.  The  heart  and  lungs  were  healthy. 
The  appetite,  however,  was  very  bad,  and  digestion  much 
impaired  ;  the  tongue  was  furred.  There  was  tenderness 
in  the  right  hypochondrium,  and  increased  dulness  in 
the  region  of  the  liver.  The  patient  was  considerably 
emaciated,  and  had  a  sallow  and  dyspeptic  complexion. 

n2 


180  SCLEROSIS  OP  THE  SPINAL  CORD. 

I  have  thus  given  somewhat  fuller  details  of  this  case 
than  of  many  others,  because  the  patient  completely 
recovered  under  treatment  from  all  symptoms  of  tabes, 
excepting  the  deafness,  which  remained  unaltered. 

The  lesion,  which  in  this  case  caused  the  vertigo  and 
the  deafness,  I  believe  to  have  affected  that  part  of  the 
auditory  nerve  which  is  situated  in  the  membranous  laby- 
rinth. The  deafness  could  not  be  considered  to  arise  from 
disease  of  Ferrier's  auditory  centre,  in  the  superior-temporo- 
sphenoidal  convolution  of  the  hemispheres  ;  for  this, 
although  the  centre  of  hearing,  has  nothing  to  do  with  the 
equilibration  of  the  body.  Nor  could  the  vertigo  be  owing 
to  disease  of  the  middle  lobe  of  the  cerebellum  ;  for  this, 
although  the  central  organ  of  equilibration,  has  nothing  to 
do  with  the  sense  of  hearing.  The  disease  must  therefore 
have  been  seated  in  the  auditory  nerve  itself,  which  pre- 
sides over  both  hearing  and  equilibration,  and  destructive 
lesions  of  which  will  cause  deafness  as  well  as  vertigo. 

At  what  part  of  the  anatomical  distribution  of  the  portio 
mollis  was  the  disease  located  ?  Evidently  not  at  its  root 
in  the  medulla,  because  there  it  is  contiguous  with  the 
sentient  root  of  the  fifth  nerve,  and  there  would,  therefore, 
no  doubt  have  been  anaesthesia  of  the  face,  together  with 
the  deafness.  A  case  of  this  latter  kind  has  been  described 
by  Professor  Moos.^  Nor  was  it  likely  that  the  nerve- 
trunk  was  affected  where  it  emerges  from  the  lower 
border  of  the  pons  Varolii.  I  believe  this  portion  of  the 
nerve  to  have  been  healthy,  because  there  was  galvanic 
response  on  applying  the  voltaic  current  to  the  ear,  and 
such  response  appears  to  be  absent  in  destruction  of  the 
nerve-trunk.  We  are,  therefore,  led  to  the  conclusion  that 
the  disease  affected  the  labyrinthine  expansion  of  the 
nerve,  comprising  its  branch  for  the  cochlea  as  well  as  for 
the  vestibule. 

*  "  American  Archives  for  Ophthalmology  and  Otology,"  vol.  ii., 
p.  199. 


SYMPTOMS  OF  TABES   SPINALIS.  181 

The  pathological  lesion  in  the  labyrinth  was  no  doubt 
of  an  inflammatory  character,  as  there  was  a  period  ex- 
tending over  rather  more  than  a  month  in  which  there  were 
evident  signs  of  special  hypersesthesia  of  the  labyrinthine 
expansion  of  the  nerve,  which  were  followed  by  special 
and  permanent  anaesthesia.  These  symptoms  correspond 
very  closely  to  those  which  I  have  observed  in  acute 
olfactory  and  trifacial  neuritis.  The  gradual  loss  of  hear- 
ing during  the  period  just  mentioned  speaks  against 
haemorrhage  in  the  labyrinth,  in  which  deafness  is  more 
suddenly  developed.  The  cord-affection  which  followed 
the  attack  of  auditory  neuritis  was  likewise  of  a  more 
markedly  inflammatory  character  than  is  usual  in  ataxy,  as 
the  symptoms  became  developed  with  far  greater  rapidity 
than  is  seen  in  the  majority  of  cases. 

Inflammation  of  the  labyrinthine  expansion  of  the  audi- 
tory nerve  I  believe  to  be  more  common  than  is  generally 
thought,  and  it  has  no  doubt  often  been  confounded  with 
congestion  or  inflammation  of  the  brain,  or  been  put  down 
to  an  attack  of  severe  dyspepsia  and  congestion  of  the  liver. 
The  chief  difference  in  the  clinical  symptoms  of  haemorrhage 
and  inflammation  is  that  the  symptoms  are  not  so  severe 
and  sudden  in  their  onset  in  the  latter,  that  they  continue 
for  a  more  considei-able  time,  and  become  gradually  more 
fully  developed.  1 

The  two  parts  of  the  auditory  nerve  may,  however,  be 
separately  affected.  The  nerve  of  space  may  suffer  either  in 
its  terminal  branches  in  the  semicircular  canals,  or  through 
sclerosis  of  its  nucleus  in  the  medulla  oblongata  or  in  its 
origin  in  the  cerebellum.  Vertigo  is,  then,  the  principal 
symptom,  and  this  may  be  associated  with  deafness  owing 
to  other  causes,  such  as  thickening  or  perforation  of  the 
membrana  tympani,  or  obstruction  of  the  Eustachian  tube, 
without  the  cochleary  nerve  being  at  all  implicated. 

'  Vide  my  Paper  on  this  subject  in  "  Brain,"  part  v.,  p.  16.  London, 
1879. 


182  SCLEROSIS  OF  THE  SPINAL  CORD. 

Slight  attacks  of  vertigo  are  not  at  all  uncommon  in  the 
first  stage  of  tabes.  The  patient  experiences  a  sensation  of 
fulness  and  swimming  in  the  head,  and  feels  as  if  every- 
thing were  spinning  around ;  he  staggers,  and  would  lose 
his  balance  unless  supported.  Sometimes  there  is  a  kind 
of  impulse  to  fall  in  a  certain  direction,  either  forward  or 
backward,  or  to  one  particular  side  (either  right  or  left). 
This  would  correspond  to  the  different  functions  of  the 
three  semicircular  canals,  and  of  the  several  portions  of 
the  middle  lobe  of  the  cerebellum,  as  determined  by  phy- 
siological experiment.  Thus  injury  of  the  superior  canal 
and  of  the  anterior  portion  of  the  middle  lobe  of  the  cere- 
bellum has  been  shown  to  cause  a  tendency  to  make  a 
somersault  forwards,  and  to  move  the  head  rapidly  for- 
wards and  backwards  ;  lesion  of  the  external  canal,  and  of 
the  lateral  lobes  of  the  cerebellum,  causes  rapid  oscillations 
of  the  head  and  eyes  from  one  side  to  the  other,  and  ten- 
dency to  spin  round  ;  while,  lastly,  injury  to  the  posterior 
canal  and  of  the  posterior  portion  of  the  middle  lobe  of  the 
cerebellum  leads  to  rapid  movements  of  the  head  back- 
wards and  forwards,  with  tendency  to  take  a  somersault 
Dackwards.  The  diagnosis  as  regards  localisation  may, 
therefore,  in  such  cases  often  be  pushed  to  a  degree  of  re- 
finement which  would  in  former  times  have  been  thought 
absolutely  impossible. 

Vertigo  is  often  accompanied  with  clammy  perspiration, 
sickness,  vomiting,  and  pain  in  the  head  and  nape  of  the 
neck.  Sometimes  the  exciting  cause  seems  to  be  a  sudden 
movement  of  the  head,  either  to  the  side  or  upwards,  or 
stooping.  Such  attacks  of  giddiness  may  come  on  even 
while  the  patient  is  in  bed  ;  he  then  feels  the  bed  move 
and  turn  from  one  side  to  the  other,  or  himself  sinking 
through  the  floor,  or  falling  out  of  bed,  or  raised  into  the 
air,  and  he  grasps  the  bedstead  or  mattress  in  order  to 
steady  himself. 

If  the  cocMeary  nerve  suffers,  the   symptoms  are  tinnitus 


SYMPTOMS  OF  TABES  SPINALIS.  183 

and  deafness.  Tinnitus  is  often  felt  as  a  ringing  of 
bells,  singing  of  birds,  buzzing  of  blue-bottles,  scream- 
ing of  steam-whistles,  explosions  of  gunpowder,  or  the 
rattling  of  an  express  train.  Such  symptoms  may 
continue  for  a  few  days,  and  then  disappear.  A  patient 
who  was  sent  to  me  by  Dr.  Pearce,  of  Leicester 
(Case  53a),  and  who  had  been  affected  with  tabes  for 
some  years,  when  staying  at  a  cold,  draughty  house, 
where  there  was  much  gas,  to  which  he  was  not  accus- 
tomed, one  night  awoke  with  a  frightful  noise  in  his  head 
as  if  he  was  in  the  underground  railway.  This  lasted 
half  an  hour  or  more,  and  then  turned  to  a  buzzing,  which 
continued  next  day.  He  had  at  the  same  time  a  scalded 
feeling  in  the  cheek,  eye  and  nose.  When  he  spoke  or  any- 
one else  spoke  to  him,  it  sounded  to  him  as  if  he  was  in 
a  diving-bell,  and  any  external  noise  seemed  to  produce  a 
curious  sound  in  his  head.  In  a  few  days  all  these  symp- 
toms had  disappeared. 

Deafness  in  tabes  may  be  quite  accidental,  and  owing  to 
various  affections  of  the  parts  which  transmit  the  sounds  ; 
such  as  accumulation  of  wax  in  the  meatus,  subacute 
or  chronic  lesions  of  the  membrana  tympani,  or  the 
middle  ear,  an  impervious  condition  of  the  Eustachian 
tube  from  previous  inflammation,  etc.  In  other  cases, 
however,  it  is  owing  to  disease  of  the  nerve  itself,  and  is 
then  generally  progressive  in  character,  so  that  the  patient 
eventually  becomes  stone-deaf.  Marie  and  Walton,^  who 
have  endeavoured  to  ascertain  the  frequency  with  which 
various  forms  of  deafness  occur  in  the  tabid,  have  found 
it,  in  seventeen  cases  out  of  twenty-four,  in  patients  who 
were  inmates  of  La  Salpetriere  ;  and  Ormerod  has  seen 
it  in  five  cases  out  of  thirteen. 

9.  Fifth-Nerve  Troubles. — I  have  already  drawn  attention 
to  the  lightning-pains  which  may  appear  in  the  sphere 
of  the  fifth  nerve  (p.  149).  Apart  from  these,  however, 
'  **  Revue  de  Medicine."     Paris,  January,  1883. 


184  SCLEROSIS  OF  THE  SPINAL  CORD. 

other  symptoms  may  show  this  nerve  to  be  implicated  in 
the  morbid  process,  which  is  then  most  probably  located  in 
the  ganglionic  cells  of  the  nuclei  of  the  trifacial  nerve  in 
the  medulla  oblongata. 

Anaesthesia  of  the  skin  of  the  face  and  scalp,  and  of  the 
mucous  membranes  supplied  by  the  fifth  nerve,  may  occur 
either  in  one  or  both  sides.  The  taste  may  be  lost,  and 
the  movements  of  the  tongue  may  become  so  awkward 
that  the  morsels  are  not  properly  moved  about  in  the  mouth 
during  mastication  and  insalivation.  Although  the  tongae 
derives  its  motor  power  from  the  hypoglossus  nerve,  and 
may,  therefore,  not  be  paralysed,  yet  the  suitable  and 
appropriate  way  in  which  the  tongue  generally  does  its 
duty  is  interfered  with.  In  fact,  there  is  ataxy  of  the 
tongue.  The  muscles  of  mastication,  which  are  supplied 
by  the  minor  portion  of  the  fifth  nerve,  may  also  be  in  a 
state  of  paresis.  At  the  same  time  there  may  be  hyper- 
secretion of  saliva  and  epiphora. 

Pierret^  has  described  the  case  of  a  patient  in  whom 
there  had  been  symptoms  of  tabes  for  nearly  three  years, 
when  the  face  began  to  twitch,  and  the  internal  branch  of 
the  palpebral  nerve  became  extremely  painful.  The  patient 
appeared  to  be  always  chewing ;  when  swallowing,  he  was 
obliged  to  do  this  very  gradually  and  with  extreme  care,  as 
otherwise  everything  "went  into  the  wrong  throat." 
Speech  was  difficult,  and  articulation  awkward  ;  when  the 
patient  was  told  to  put  out  his  tongue  there  were  odd  and 
jerky  movements  about  the  mouth,  and  the  tongue  was 
tremulous.  Three  years  later  all  the  muscles  of  the  eye 
were  paralysed  ;  the  patient  kept  chewing  constantly  ;  the 
saliva  ran  away  from  the  corner  of  the  mouth  ;  the  jaws 
were  so  weak  in  their  movements  that  the  teeth  did  not 
meet  on  attempting  to  bite  off  a  morsel,  and  the  patient 
had  the  greatest  difficulty  in  seizing  anything  placed  in 
his  mouth  between  the  teeth. 

^  "  Essai  sur  les  Symptomes,"  etc.,  p.  42. 


SYMPTOMS  OF  TABES  SPINALIS.  185 

In  another  case  reported  by  the  same  observer  (I.e.,  p.  44) 
there  was,  apart  from  other  symptoms  of  tabes,  almost 
complete  anaesthesia  of  the  mucous  membrane  of  the 
mouth  and  the  tongue.  The  patient  said  he  had  lost  his 
palate  ;  condiments  were  not  tasted,  nor  was  tobacco. 
The  tongue  had  become  clumsy  and  awkward,  and  could 
not  move  a  morsel  in  the  mouth.  There  were  lightning 
pains  in  the  teeth  on  both  sides.  Mastication  was  difficult ; 
the  patient  could  not  whistle.  Speech  was  impaired,  and 
the  tongue  was  subject  to  incoordinated  movements. 
The  nasal  fossae  were  likewise  somewhat  anaesthetic,  and 
the  patient  complained  of  a  constant  bad  smell.  He  also 
suffered  from  tinnitus  and  some  degree  of  deafness  in  the 
left  ear. 

Hemi-atrophy  of  the  tongue  is  also  occasionally  seen 
quite  in  the  beginning  of  tabes,  and  may  affect  either 
side  of  the  organ  ;  one  half  of  it  shows  furrows  and  fissures, 
and  is  the  seat  of  tremor  from  fibrillary  contractions.  It 
may  be  slightly  deviated  to  the  opposite  side.  It  does  not 
appear  to  cause  much  trouble  in  speaking,  masticating  or 
swallowing,  and  is  generally  associated  with  palsies  of  the 
ocular  muscles  and  atrophy  of  certain  sets  of  muscles  in 
the  extremities.  This  symptom  has  as  yet  only  been 
seen  in  syphilitic  subjects,  and  should  therefore,  when  seen, 
excite  suspicion  of  that  dyscrasia.  I  believe  it  to  be 
owing  to  sclerosis  of  certain  trophic  fibres  in  the  course 
of  the  fifth  nerve,  as  I  have  seen  a  considerable  degree 
of  atrophy  in  the  whole  organ  in  a  patient  who  was 
affected  with  bilateral  disease  of  the  fifth  pair,  without 
any  other  morbid  condition. 

10.  The  portio  dura  and  the  glosso-i^haryngeal  nerve. — 
These  nerves  appear  to  be  but  rarely  affected.  I  have 
already  related  the  case  of  a  patient  (p.  119)  who  was 
under  my  care  at  the  hospital  in  February,  1878, 
who  had  had  syphilis  when  seventeen  years  of  age,  and 
afterwards  double  vision  and  Westphal's  symptom.     When 


186  SCLEROSIS  OF  THE  SPINAL  CORD. 

he  came  under  my  care,  he  had  paralysis  of  the  left  portio 
dura  in  the  first  portion  of  the  Fallopian  canal,  viz.,  facial 
palsy,  loss  of  reflex  excitability  and  of  faradic  contractility, 
and  increased  response  of  the  facial  muscles  to  the  constant 
voltaic  current ;  but  no  symptoms  showing  any  implication 
of  the  chorda  tympani,  the  stapedian  nerve,  or  the  gang- 
lion geniculum.  He  had  also  paralysis  of  the  left  rectus  ex- 
ternus  of  the  eye.  Two  and  a  half  years  ago  he  had  had  a 
temporary  attack  of  hemiplegia  of  the  left  side,  from  which 
he  had  completely  recovered  in  three  weeks  This  ren- 
dered the  syphilitic  nature  of  the  nerve-lesion  certain. 

Ataxy  of  the  facial  muscles  has  also  occasionally  been 
observed.  As  long  as  the  patient  does  not  speak,  and  is 
not  under  the  influence  of  emotions,  nothing  particular  is 
noticed  ;  but  when  he  converses,  and  more  especially  when 
he  gets  excited  in  talking,  the  features  are  seen  to  work  in 
all  directions,  without  synergy  or  co-ordination,  producing 
grimaces  ;  and  this  ataxy  may  also  be  seen  in  the  muscles 
of  the  tongue,  soft  palate,  and  larynx.  Conversation  may 
then  become  very  fatiguing,  and  the  speech  affected.  In 
such  cases  the  hypoglossus  nerve  is  most  probably  also 
implicated. 

Symptoms  on  the  part  of  the  glosso-pTiaryngeal  nerve 
appear  to  be  rare  ;  occasionally,  however,  the  uvula  has 
been  seen  to  be  deviated  by  paralysis  of  the  azygos 
uvulae,  which  is  supplied  by  the  glosso-pharyngeal  nerve. 
There  may  be  also  anaesthesia  of  the  pharyngeal  mucous 
membrane,  rendering  deglutition  difficult. 

11.  Crises  and  other  symptoms  in  the  sphere  of  the  pneumo- 
gastric  nerve. 

a.  Laryngeal  crises  were  first  shown  to  be  a  symptom  of 
tabes  by  Fereolin  1868,  and  afterwards  investigated  chiefly 
by  the  French  school  of  pathologists,  such  as  Vulpian, 
Charcot,  Krishaber,  Demange,  Lecocq,  Cherehevsky,  and 
Dreyfus-Brissac.  These  symptoms  seem  to  be  more  frequent 
in  France  than  elsewhere,  and,  singularly  enough,  the  only 


SYMPTOMS  OP  TABES  SPINALIS.  187 

two  patients  in  whom  I  have  observed  them  happened  to  be 
Frenchmen.  They  may  be  amongst  the  first  symptoms  of 
tabes,  or  appear  only  at  a  more  advanced  period  of  the 
disease  ;  and  they  differ  from  other  laryngeal  affections 
by  the  circumstance  that  they  are  entirely  spasmodic  in 
character,  and  unconnected  with  any  catarrh  or  other 
affection  of  the  larynx,  the  windpipe,  the  bronchial  tubes, 
or,  indeed,  of  any  portion  of  the  respiratory  organs. 

Three  different  forms  of  these  crises  may  be  dis- 
tinguished, according  to  the  degree  of  severity  which 
they  assume  : — 

a.  The  slight  attacks  resemble  ordinary  whooping 
cough  ;  there  is  a  succession  of  short,  dry,  loud,  convulsive 
expiratory  efforts,  followed  by  a  long  whistling  or  whoop- 
ing inspiration  ;  the  face  appears  red  and  congested,  even 
cyanotic  ;  the  patient  is  excited  and  anxious  ;  there  is  no, 
or  only  very  slight,  expectoration,  but  a  tickling  or  pricking 
sensation  in  the  throat.  Such  fits  of  coughing  may  come  on 
without  any  apparent  cause,  or  in  consequence  of  a  sudden 
impression  of  cold,  or  from  excitement  or  emotion,  or  through 
indigestion,  and  they  last  from  ten  to  about  ninety  seconds. 
There  may  be  forty  or  fifty  such  attacks  in  a  day  ;  and 
they  are  often  wonderfully  persisting,  and  rebellious  to 
treatment.  One  of  my  patients  in  whom  they  occurred, 
and  whom  I  had  the  opportunity  of  observing  for  two 
years  consecutively,  was  rarely  a  day  free  from  them, 
winter  or  summer. 

/3.  Attacks  of  medium  severity  are  marked  by  great  dyspncca, 
stridulous  breathing,  and  a  feeling  of  impending  suffocation. 
The  face  and  conjunctiva  appear  more  congested  and 
cyanotic  ;  the  eyes  protrude  ;  the  patient  gasps  for  breath, 
and  is  on  the  point  of  choking.  There  may  be  epileptiform 
symptoms,  such  as  biting  of  tongue,  convulsions  in  the 
limbs,  and  involuntary  evacuation  of  the  urine.  Conscious- 
ness, however,  is  not  lost ;  on  the  contrary,  the  patient 
has  the  most   fearful  sensations   of  impending    death   by 


188  SCLEROSIS  OF  THE  SPINAL  CORD. 

strangling  or  suffocation.  There  are  headache,  vertigo, 
and  vomiting.  Such  an  attack  may  come  on  suddenly 
during  sleep,  reach  at  once  its  maximum  of  severity,  and 
last  from  five  to  ten  minutes,  after  which  all  the  symp- 
toms vanish  at  once,  leaving  the  patient  breathless  and 
exhausted,  but  otherwise  well. 

7.  The  worst  attacks  are  those  of  actual  apnoea.  The 
laryngeal  spasm  is  so  violent  that  the  glottis  seems  to  be 
quite  closed,  and  respiration  completely  arrested.  The 
patient  falls  down  as  in  a  fit,  is  unconscious,  and  may  be 
convulsed  or  not.  The  symptoms  therefore  resemble  those 
of  epilepsy,  or  of  the  severest  form  of  apoplexy.  The 
patient  may  die  in  the  fit,  the  heart's  action  being  likewise 
presently  arrested.  Krishaber  has  in  such  a  case  per- 
formed tracheotomy,  and  thereby  probably  saved  the  life 
of  his  patient.  After  the  operation,  the  crises  became 
subdued,  the  laryngeal  spasm  being  much  less  severe.  The 
patient  no  longer  lost  his  consciousness  in  such  fits,  and 
seemed  to  have  rather  more  spasm  in  the  diaphragm  than 
in  the  larynx.  This  man  wore  a  canula  for  some  years 
afterwards,  and,  when  he  felt  an  attack  coming  on,  opened 
it  at  once  in  order  to  allow  air  to  enter  the  windpipe. 
Attacks  of  this  latter  kind  may  come  on  quite  suddenly, 
or  be  preceded  by  a  kind  of  laryngeal  aura,  such  as  a  prick- 
ing, burning,  or  scratching  sensation  in  the  throat.  Sudden 
draughts  of  cold  air,  or  prolonged  exposure  to  cold,  appear 
to  be  the  exciting  causes.  They  may  come  on  several- 
times  a  day,  and  then  suddenly  disappear  for  months  or 
years.  They  last  longer  than  the  less  severe  attacks,  viz., 
from  twenty  minutes  to  two  or  three  hours. 

The  laryngoscopic  examination  of  the  throat  and  wind- 
pipe yields,  as  a  rule,  completely  negative  results  as  far 
as  any  structural  alterations  of  these  parts  are  concerned. 
There  appears  to  be,  however,  in  general  a  hypersesthesia 
of  the  laryngeal  mucous  membrane,  and  consequently  undue 
reflex  excitability.     This   is,  no  doubt,  owing  to  sclerotic 


SYMPTOMS  OF  TABES  SPINALIS.  189 

irritation  of  the  nucleus  of  the  vago-accessory  nerve  in  the 
medulla  oblongata.  In  a  case  of  this  kind,  Cruveilhier 
found  wasting  of  the  roots  of  this  nerve,  as  well  of  the 
posterior  pyramids  and  softening  in  the  corpora  resti- 
f ormia.  Cherchevsky  ^  has  noticed  laryngeal  crises  to  pre- 
cede the  outbreak  of  other  symptoms  of  tabes  for  thirteen 
years,  just  as  optic  atrophy  may  precede  the  evolution  of 
other  signs  of  the  disease  for  a  considerable  time.  He  does 
not  state  whether  there  is  loss  of  knee-jerk  on  the  first 
occurrence  of  such  laryngeal  crises  ;  but  such  is  most  pro- 
bably the  case.  Laryngeal  crises  must  therefore  be  looked 
upon  not  simply  as  coincidences,  but  as  actual  legitimate 
symptoms  of  tabes,  which  owe  their  origin  to  sclerotic 
irritation  of  the  nuclei  of  the  laryngeal  branches  of  the 
pneumogastric  nerve,  causing  more  or  less  violent  spasm 
in  the  adductors  of  the  vocal  cords. 

b.  Paralysis  of  the  Abductors  of  the  Vocal  Cords  is 
another  symptom  which  is  occasionally  observed  in  tabes. 
Dreschfeld  ^  has  recorded  a  case  in  which  the  laryngoscope 
showed  paralysis  of  these  muscles  on  inspiration,  while  the 
adductors  acted  normally.  The  patient's  voice  was  un- 
changed and  clear  ;  but  he  experienced  slight  dyspnoea  on 
walking,  and  during  sleep  his  breathing  was  accompanied 
by  a  loud  stridor. 

Felix  Semon^  has  shown  that,  where  there  is  central 
or  peripheral,  acute  or  chronic  organic  disease  or  injury  of 
the  centres  or  trunks  of  the  motor  nerves  of  the  larynx, 
there  is  always  either  isolated  paralysis  of  the  abductors  of 
the  vocal  cords,  or  that  at  least  their  paralysis  is  developed 
at  an  earlier  period,  and  more  complete,  than  that  of  the 
adductors,  always  supposing  that  there  is  not  absolute  trans 
verse  division  of  the  parts,  and  therefore  not  complete 
paralysis,  and  that  the  cause  is  one  of  gradual  invasion  and 

*  *•  Revue  de  Medecine,"     Paris,  July,  1881. 
3  **  Medical  Times  and  Gazette,"  Sept.  17,  1884. 


3   (( 


Berliner  klinische  Wochenschrift,"  No.  46,  1883. 


190  SCLEROSIS  OF  THE  SPINAL  CORD. 

progression.  It  appears  that  not  a  single  case  has  been 
recorded  by  any  laryngoscopic  observer  where  primary 
structural  disease  of,  or  injury  to,  the  brain  or  the  nerve - 
trunks  had  given  rise  to  isolated  paralysis  of  the  adductors 
of  the  glottis.  On  the  other  hand,  in  all  functional  affec- 
tions of  the  motor  laryngeal  nerves,  more  especially  in 
hysterical  aphonia,  there  appears  to  be  a  peculiar  tendency 
to  paralysis  of  the  adductors,  while  paralysis  of  the 
abductors  under  such  circumstances  is  an  event  of  the  most 
exceptional  occurrence.  Possibly,  even  where  cases  of  the 
latter  kind  have  occurred,  they  have  after  all  been  such  of 
structural  rather  than  functional  affection.  Thus  Buzzard 
thinks  it  probable  that  a  case  observed  by  Mackenzie  and 
Semon,  in  which  there  had  also  been  temporary  ocular 
paralysis,  was  really  a  case  of  tabes  ;  but  the  case  appears 
incomplete,  as  the  knee-jerk  had  not  been  examined. 
Rosenbach,  and  after  him  Semon,  have  drawn  attention  to 
the  analogy  which  exists  between  the  tendency  of  the 
extensors  and  abductors  of  the  limbs  to  be  affected  with 
preference,  rather  than  the  flexor  and  adductors,  in  organic 
disease  of  the  nervous  centres. 

It  appears  from  this  that  if  a  vocal  cord  be  found  im- 
movable in  the  position  of  phonation,  and  if  there  be  no 
disease  of  the  crico-arytsenoid  articulation  or  some  myo- 
pathic process,  this  would  lead  to  the  suspicion  of  disease 
between  the  nucleus  of  the  vago-accessory  and  the  peri- 
pheral branches  of  the  recurrent  nerve,  while  inspiratory 
position  of  the  paralysed  vocal  cord  or  cords  renders  it 
probable  that  the  disease  is  local  or  functional. 

Unilateral  abductor  paralysis  does  not  cause  any  symp- 
toms either  concerning  respiration  or  phonation.  If  only 
one  crico-aryt£enoid  posticus  muscle  is  paralysed,  the  corre- 
sponding cord  at  first  assumes  the  cadaverous  position,  but 
after  a  time  a  contracture  of  the  antagonists  is  caused, 
and  the  cord  is  drawn  inwards,  and  eventually  becomes 
completely  fixed  in  the  median  position.     For  this  reason 


SYMPTOMS  OF  TABES  SPINALIS.  191 

tranquil  respiration  in  the  adult  remains  unimpaired.  It  is 
true  that  during  emotional  excitement,  efforts,  etc.,  dys- 
pnoea may  appear,  but  it  is  slight,  and  probably  more  owing 
to  the  complaint  which  really  causes  the  palsy.  The  latter 
can,  therefore,  only  be  recognised  by  a  laryngoscopic  ex- 
amination, which  is  thus  shown  to  be  a  very  important  aid 
in  diseases  of  the  nervous  centres  as  well  as  of  the  thoracic 
viscera,  in  which  the  nuclei  or  fibres  of  the  recurrent  nerve 
may  become  affected. 

c.  Paresis  or  paralysis  of  the  pharyngeal  branches  of  the 
pneumogastric  nerve  may  lead  to  difficulty  of  swallowing 
and  regurgitation  of  liquids  through  the  nose  ;  and  when 
this  occurs  together  with  weakness  in  the  legs,  it  may  be 
mistaken  for  diphtheritic  paralysis.  In  other  cases  there 
is  from  time  to  time  a  spasm  in  the  gullet,  which  renders 
swallowing  impossible  ;  and  this  may  be  so  severe  as  to 
amount  to  actual  pharyngism  or  oesophagism,  and  be 
accompanied  with  severe  pain. 

d.  Gastric  crises  constitute  one  of  the  most  singular  and 
important  symptoms  of  tabes  spinalis.  They  may  be,  if 
not  actually  the  first,  yet  one  of  the  first  signs  of  that 
protean  disease  ;  and  as  cases  of  this  kind  have  in  former 
times  been  frequently  confounded  with  congestion  of  the 
liver,  ulcer,  or  cancer  of  the  stomach,  gout  in  the  stomach, 
or  believed  to  be  owing  to  hysteria,  lead-poisoning,  or 
nephritic  colic,  or  to  cancer  of  the  womb,  ileus,  volvulus, 
&c.,  Dolamore's  ^  discovery  that  they  may  arise  in  the  tabid, 
and  are  a  special  symptom  of  this  malady,  constitutes  an 
important  progress  in  diagnosis  altogether. 

The  principal  symptoms  of  gastric  crises  are  pain  and 
vomiting  ;  and  these  may  either  occur  together,  or  there 
may  be  only  one  of  these  signs.  The  pain  which  is  experi- 
enced, more  especially  in  the  hypogastrium,  is  truly  agonis- 
ing, and  may  radiate  from  the  pit  of  the  stomach  to   the 

'  "  Des  troubles  gastriques  dans  I'ataxie  locomotiice."  These  de 
Paris,  1868. 


192  SCLEROSIS  OF  THE  SPINAL  CORD. 

chest,  abdomen,  and  the  os  pubis.  It  may  resemble  a 
scald,  or  take  the  various  other  characters  of  lightning-pains 
(p.  146).  It  is  often  so  excessive  that  the  patient  keeps  on 
yelling  at  the  top  of  his  voice  for  hours,  and  eventually 
faints  away,  and  remains  for  a  considerable  time  in  a  state 
of  syncope.  A  case  is  mentioned  by  Vulpian  where  a  man, 
under  the  influence  of  this  pain,  knocked  one  thigh  so 
violently  against  the  other,  that  he  broke  the  bone  ;  and 
squeezed  his  arm  so  forcibly  that  he  brought  on  paralysis 
of  the  muscles  supplied  by  the  musculo-spiral  nerve,  through 
compression  of  the  latter.  Such  pain  may  continue  for  a 
whole  week  incessantly,  and  be  hardly  relieved  by  the  most 
powerful  sedatives,  when  all  of  a  sudden  it  disappears  as 
if  by  enchantment,  and  the  patient  feels  that  the  attack 
is  over. 

Vomiting  of  food,  mucus,  bile,  and  coffee-ground  matter, 
containing  blood,  is  often  superadded  to  it  ;  but  it  may 
be  the  only  symptom  of  the  crisis.  The  vomiting  may  also 
be  incessant,  so  that  everything  that  is  taken,  either  in  the 
shape  of  food  or  medicine,  is  brought  up  as  soon  as  swal- 
lowed, and  the  patient  ultimately  refuses  to  take  anything 
at  all.  After  the  stomach  has  been  completely  emptied, 
vomiting  and  efforts  at  vomiting  nevertheless  continue, 
and  then  cause  even  greater  exhaustion.  Spasmodic  sin- 
gultus, eructations,  cough,  and  meteorism  are  added,  and 
the  patient  sometimes  has  a  sensation  as  if  his  stomach 
were  forcibly  torn  from  his  body.  All  this  may  last  a  few 
days,  but  it  may  also  go  on  for  months,  causing  great 
emaciation,  and  leading  ultimately  to  death  by  inanition. 
The  vomiting  may,  like  the  pain,  also  disappear  suddenly, 
and  apparently  without  being  influenced  by  treatment. 
Such  crises  may  occur  every  few  weeks,  and  are  then  gene- 
rally put  down  to  ulcer  or  malignant  disease  of  the  stomach, 
more  especially  when  the  vomit  is  of  the  coffee-ground 
character.  Blood  may  also  be  passed  by  the  bowels  and 
with  the  urine,  and,  in  women,  from  the  womb.     During 


SYMPTOMS  OF  TAliES  SPINALIS.  193 

the  crisis  the  pulse  generally  becomes  very  slow,  falling 
occasionally  to  twenty-eight  beats  in  the  minute. 

Case  54. — In  October,  1882,  the  secretary  of  the  Amal- 
gamated Society  of  Carpenters  and  Joiners  requested  me  to 
see  one  of  their  members,  who  had  for  two  years  been 
unable  to  work,  and  now  claimed  the  benefit  which  that 
society  allows  to  its  disabled  members.  This  man,  who 
was  thirty  years  old,  but  looked  at  least  ten  years  older, 
denied  having  ever  had  any  syphilitic  infection,  or  com- 
mitted any  excesses  in  drinking,  smoking,  or  sexual  indul- 
gence, but  attributed  his  illness  to  prolonged  exposure 
to  cold,  about  two  years  ago.  The  first  symptoms  were 
violent  attacks  of  vomiting,  with  great  pain  in  the  stomach, 
which  came  on  from  time  to  time  quite  suddenly,  without 
any  apparent  cause.  He  would  bring  up  first  mucus,  then 
any  food  which  he  might  have  taken  before,  and  eventually 
bile.  Such  an  attack  lasted  generally  about  twelve  hours, 
during  which  vomiting  and  retching  would  be  incessant, 
and  not  reheved  by  any  medicine.  At  the  expiration  of  the 
time  mentioned,  the  symptoms  would  cease  as  suddenly 
as  they  came.  A  few  months  after  the  first  of  these 
attacks,  the  patient  was  seized  with  double  vision,  which, 
however,  left  him  after  a  time.  He  then  began  to  suffer 
from  lightning-pains  in  the  extremities,  more  especially  the 
left  arm  and  leg.  At  present  there  was  a  considerable 
amount  of  anaesthesia  and  analgesia,  chiefly  in  the  left 
side ;  loss  of  knee-jerk  on  both  sides  ;  ataxy  of  gait  and 
Eomberg's  symptom  ;  a  wasted  and  flabby  condition  of 
the  muscles  ;  incontinence  of  urine,  constipation  of  the 
bowels,  and  loss  of  sexual  desire  and  power,  rendering 
the  diagnosis  of  tabes  certain. 

Gastric  crises  occasionally  alternate  with  attacks  of 
lightning-pains,  so  that  a  patient  has  hardly  recovered  from 
the  former,  when  he  is  seized  by  the  latter,  whereby  his  life 
is  rendered  truly  intolerable.  Even  if  the  vomiting  be 
not  prolonged,  attacks  of  this  kind  leave  their  mark  on  the 

o 


J94  SCLEROSIS  OF  THE  SPINAL  CORD. 

patient's  constitution,  which  is  afterwards  much  less  able  to 
resist  injurious  influences  and  more  liable  to  give  way 
under  a  slighter  strain. 

Whether  these  symptoms  are  owing  entirely  to  derange- 
ment of  the  pneumogastric,  or  also  of  the  sympathetic 
system  of  nerves,  is  at  present  not  yet  determined.  It  has 
been  assumed  that  the  phenomena  of  pain  and  spasm  are 
due  to  irritation  of  the  pneumogastric  and  the  intercostal 
and  spinal  nerves  associated  with  it,  while  such  sufferings 
as  faintness,  distension,  palpitation,  flatulence,  retching  and 
vomiting  are  owing  to  the  sympathetic  nerve-disturbance. 
The  lowering  of  the  rate  of  pulsation  which  so  often  accom- 
panies these  crises,  however,  would  certainly  seem  to  point 
to  the  pneumogastric  as  the  principal  nerve  involved. 

e.  Cardiac  Symptoms. — The  pulse  in  tabes  ranges  habi- 
tually from  100  to  120  beats,  and  even  more,  showing  loss  of 
power  in  the  cardiac  branches  of  the  pneumogastric  nerve, 
which  is  the  regulator  of  the  heart's  action.  The  pulse  is 
also  frequently  small  and  compressible.  Ley  den  has  seen 
two  cases  of  cardiac  crises,  with  dyspnoea  and  irregular 
pulse.  During  severe  attacks  of  lightning  pains,  and 
o-astric  or  intestinal  crises,  the  rate  of  pulsation  is  apt  to 
become  very  slow. 

12.  The  Spinal  Accessory  Nerve  does  not  seem  to  be  very 
frequently  affected.  In  July,  1878,  however,  I  had  a 
patient,  aged  45,  under  my  care,  at  the  hospital,  who  had 
had  syphilis  twelve  years  ago,  and  in  whom  tabes  began  with 
liffhtnino'-pains  in  the  shoulders  and  arms,  and  torticollis 
from  spasm  of  the  left  trapezius  muscle.  This  latter  lasted 
for  about  three  months,  and  then  disappeared,  together  with 
improvement  in  the  other  symptoms. 

13.  Early  Cerebral  troubles. — a.  Aphasia  and  Paralysis. 
— rAttacks  of  aphasia,  monoplegia,  and  hemiplegia,  with  or 
without  loss  of  consciousness,  are  by  no  means  uncommon 
in  the  first  stage  of  tabes.  They  are  often  ushered  in  by 
a  feeling  of  giddiness,  which  gradually  merges  into  coma  ; 


SYMPTOMS  OF  TABES  SPINALIS.  195 

and  paralysis  of  one  or  several  limbs  may  then  be  discovered. 
These  cases  look  at  first  sight  like  cases  of  cerebral  haemor- 
rhage or  embolism  of  an  important  artery  in  the  brain  ; 
but  as  recovery  takes  place  in  two  or  three  days,  or  at  most 
in  two  or  three  weeks,  it  is  evident  that  they  are  not  owing 
to  any  gross  organic  lesions. 

The  pathology  of  these  cases  is  obscure,  the  most  pro- 
bable supposition  being  that  they  are  owing  to  some  dis- 
turbance in  the  vaso-motor  system  of  nerves.  This  may  be 
spasm,  causing  ischaemia  and  temporary  failure  of  blood 
supply  to  those  portions  of  the  brain  which  are  affected  ; 
or  paralysis,  causing  excessive  hyperagmia  in  the  blood- 
vessels and  increase  of  intra- vascular  pressure.  Similai 
attacks  occur  in  alcoholism,  senile  dementia,  insular  scle- 
rosis, and  the  first  stage  of  general  paralysis  of  the  insane. 
An  examination  of  the  knee-jerk,  which  is  probably  always 
lost  where  these  symptoms  occur  in  the  tabid,  will  often 
be  necessary  in  order  to  settle  the  diagnosis. 

Attacks  of  this  kind  appear  to  be  sometimes  connected 
with  laryngeal  crises  and  epileptiform  seizures,  and  may 
possibly  be  occasionally  owing  to  the  former.  In  some 
cases  it  is  impossible  to  distinguish  a  severe  laryngeal 
crisis  from  an  epileptic  attack. 

A  case  in  which  hemiplegia  of  the  left  side  appeared  to 
be  the  first  symptom  of  tabes  has  already  been  mentioned 
(Case  29,  p.  119).  The  patient,  who  was  then  only  nineteen 
years  of  age,  but  had  had  syphilis  at  seventeen,  recovered 
completely  from  the  hemiplegia  in  three  weeks.  Some- 
times, however,  hemiplegia  occurs  at  a  time  when  the 
usual  symptoms  of  tabes  in  its  second  stage  are  fully 
established. 

Case  55. — In  August,  1883,  Dr.  Schmitz,  of  Neuenahr, 
sent  to  me  a  steward,  aged  sixty-three,  a  widower  with 
one  child,  who  had  for  some  time  past  been  under  treat- 
ment for  diabetes,  and  had  visited  Neuenahr  in  order  to 
drink  the   waters  there  for    the    cure    of    that   affection. 

o2 


196  SCLEROSIS  OF  THE  SPINAL  CORD. 

Almost  immediately  on  his  arrival  there,  however,  he  had 
an  attack  of  hemiplegia  of  the  right  side,  with  aphasia, 
which  rendered  the  Spa  treatment  impossible.  He  recovered 
rapidly  from  the  hemiplegia,  and  Dr.  Schmitz  then  advised 
the  patient  to  return  home.  When  I  saw  him,  I  found  the 
symptoms  of  ataxy  fully  developed,  both  in  the  upper  and 
lower  extremities.  The  patient  was  quite  helpless,  had 
Romberg's,  Westphal's,  and  Argyll-Robertson's  symptoms, 
obstinate  constipation  of  the  bowels,  and  incontinence  of 
urine.  There  was  no  trace  of  the  hemiplegia  left.  The 
patient  was,  however,  so  confused  in  his  mind,  and  had  so 
much  difficulty  in  remembering  things  and  expressing  him- 
self intelligibly,  that  no  further  history  of  his  case  could 
be  elicited. 

Where  aphasia  and  hemiplegia  appear  in  the  latest  stages 
of  the  disease,  they  are  generally  permanent,  and  produced 
by  organic  changes  in  the  vascular  supply  of  the  brain, 
causing  destructive  softening  of  the  cerebral  matter. 
Debove  ^  has  related  the  case  of  a  man,  aged  forty-eight, 
who  had  for  a  number  of  years  suffered  from  tabes,  and  was 
suddenly  seized  by  right  hemiplegia  and  aphasia,  which 
disappeared  within  a  fortnight.  Four  years  afterwards 
he  had  a  similar  attack,  but  the  symptoms  then  persisted, 
and  death  ensued  a  few  weeks  afterwards.  Apart  from  scle- 
rosis of  the  posterior  columns  of  the  entire  cord,  there  was 
also  found  an  area  of  softening  in  the  left  half  of  the  pons 
Varolii,  with  secondary  descending  degeneration  ;  but  there 
was  nothing  to  indicate  the  attack  which  had  taken  place 
four  years  before.  In  another  case,  that  of  a  patient,  aged 
fifty-eight,  tabes  had  existed  for  twenty  years  when  he 
came  under  observation.  He  had  an  attack  of  aphasia  and 
right  hemiplegia  in  the  eighth  year  of  the  tabes  ;  and  these 
phenomena  eventually  disappeared  in  about  eighteen 
months.  Seventeen  years  afterwards  he  was  still  alive, 
and  although  tabid,  was  not  paralysed.  Buzzard,  Ballet 
1  «'Progres  Medical,"  Nos.  52  and  53.     Paris,  1881. 


SYMPTOMS  OF  TABES  SPINALIS.  197 

and  Bernhardt  ^  have  recorded  analogous  cases,  and 
Westphal  has  seen  a  man  brought  into  the  hospital  for 
hemiplegia,  when  the  loss  of  the  knee-jerk  in  the  paralysed 
limb  led  him  to  make  the  diagnosis  of  tabes.  It  is,  there- 
fore, seen  how  important  Westphal's  symptom  is  for  the 
diagnosis  of  such  complications  of  the  principal  disease* 
Lecoq^  who  has  collected  a  number  of  similar  cases,  has 
likewise  come  to  the  conclusion  that  attacks  of  apoplexy 
are  integral  symptoms  of  tabes,  which  may  occur  at  every 
stage  of  the  disease,  either  by  themselves,  or  associated 
with  laryngeal  crises  and  epileptiform  seizures. 

b.  Epileptic  seizures  may  likewise  appear  in  the  first 
stage  of  the  malady,  and  assume  the  form  of  general  con- 
vulsions, with  loss  of  consciousness,  or  of  2^^^  mat.  In 
some  cases  these  attacks  are  apt  to  recur  at  more  or  less 
regular  intervals,  while  in  others  there  is  only  a  history  of 
a  succession  of  fits  on  one  particular  occasion. 

Case  ^^. — In  January,  1880,  Dr.  Schulhof,  of  Brook- 
street,  asked  me  to  see  with  him  a  merchant,  aged  fifty- 
three,  single,  who  had  had  syphilis  badly  six  years  ago. 
The  secondary  manifestations  ceased  after  six  months,  and 
the  patient  believed  himself  to  be  well,  when  two  years 
afterwards  he  was,  without  any  warning,  suddenly  seized 
by  an  epileptic  fit,  in  which  he  lost  his  consciousness,  bit 
his  tongue,  foamed  at  the  mouth,  passed  his  water,  and 
was  generally  convulsed  for  about  five  minutes.  This  fit 
was  followed  by  several  other  similar  ones  on  the  same  day. 
On  no  subsequent  occasion  had  he  had  any  other  epilepti- 
form seizures  or  cerebral  symptoms  of  any  description  ;  but, 
soon  after  the  series  of  attacks  which  he  had  had  in  1876, 
various  symptoms  of  spinal  disease  began  to  make  their 
appearance,  and  had  become  steadily  worse  when  I  saw 
the  patient.  He  complained  chiefly  of  incessant  nocturnal 
emissions  of  semen,  which  occurred  four  nights  out  of  five, 

'  **  Archiv  fiir  Psychiatrie,"  vol.  xiv.,  p.  142.     Berlin,  1883. 
2  '♦  Revue  de  Medecinc."    Paris,  June,  1882. 


198  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  sometimes  several  times  in  one  night.     This  trouble 

nearly  drove  him  to  desperation.     He  also  had  ataxy  of 

gait,  and  most  of  the   symptoms  of  the  second  stage  of 

tabes. 

c.  Failure  of  brain  power  and  mental  alteration  of  some 

kind  is  not  uncommon  in  the  first  stage  of  the  disease. 
The  patient,  who  has  previously  been  cheerful,  interested 
in  his  occupation,  and  affectionate  to  his  family,  becomes 
morose,  taciturn,  irritable,  timid,  and  indifferent  to  his 
interests.  Sometimes  there  is  so  much  mental  depression 
that  he  bursts  out  crying  at  the  least  provocation  or  with- 
out any  cause  at  all.  Suicidal  ideas  are  rife,  and  are 
occasionally  acted  upon. 

Case  57. — A  merchant,  aged  fifty-three,  married  and 
father  of  four  children,  consulted  me  in  December,  1881. 
He  complained  of  intense  depression  of  spirits,  saying  that 
he  felt  as  if  the  grey  matter  of  his  brain  did  not  act,  and 
that  if  a  new  lining  conld  be  put  into  it,  he  would  be 
better.  He  also  felt  very  restless,  slept  badly,  and  had 
frontal  headache.  There  was  some  amount  of  divergent 
strabismus  in  the  left  eye;  and  some  months  ago  he  had 
been  much  troubled  with  double  vision.  He  had  had 
syphilis  about  ten  years  ago,  and  also  several  attacks  of 
obstinate  gonorrhoea  at  various  times.  He  had  lost  his 
sexual  power,  but  had  no  trouble  with  his  bladder  or 
bowels.  He  suffered,  however,  much  from  frequent  emis- 
sions of  semen  in  his  sleep.  The  knee-jerk  was  entirely 
lost  on  both  sides,  while  the  quadriceps  femoris  showed 
increased  excitability  to  direct  percussion.  There  were 
no  other  symptoms  of  tabes.  I  did  not  see  the  patient 
again  until  August,  1883,  when  he  complained  of  nothing 
fresh,  but  appeared  a  prey  to  intense  melancholia.  Three 
weeks  afterwards  he  died  suddenly,  and  I  was  given  to 
understand  that    he  had  committed  suicide. 

Case  58. — A  contractor  in  a  very  large  way  of  business, 
aged  fifty-one,  married  but  childless,  consulted  me  in  De- 


SYMPTOMS  OF  TABES  SPINALIS.  199 

cember,  1882.  He  denied  having  had  syphilis,  but  had 
notoriously  led  a  very  rackety  life.  He  complained  of 
failure  of  brain  power  which  had  come  on  rather  suddenly 
about  six  months  ago.  While  formerly  he  directed  with 
the  greatest  facility  all  the  intricacies  of  enormous  com- 
mercial transactions,  and  the  most  complicated  matters  ap- 
peared to  him  like  child's-play,  he  had  suddenly  found 
himself  unable  to  attend  to  his  avocations,  to  collect  his 
thoughts  or  even  to  compose  a  letter.  He  could  simply  do 
nothing,  and  would  sit  crying  in  his  room  all  day  long.  He 
had  been  under  the  care  of  the  heads  of  the  profession  in 
Paris,  but  received  no  benefit.  Although  the  case  appeared 
to  be  at  first  sight  one  of  simple  break-down  of  his  mental 
faculties  from  over-exertion,  the  presence  of  Westphal's 
symptom  which  I  ascertained  during  my  examination  of  the 
patient,  led  me  to  enquire  about  symptoms  of  tabes.  It 
then  appeared  that,  at  the  beginning  of  his  illness,  he  had 
increased  sexual  desire,  which  had,  however,  now  been 
changed  into  complete  anaphrodisia  and  impotency  ;  he 
also  suffered  from  constipation  of  the  bowels,  and  difficulty 
of  urination  ;  and  had  occasionally  had  shooting  pains  in 
the  lower  extremities.  These  were  the  only  positive 
symptoms  of  tabes  which  I  could  discover,  but  which, 
in  connection  with  Westphal's  symptom,  left  no  doubt  on 
my  mind  that  the  failure  of  brain  power  was  only  a  symp- 
tom of  a  more  general  disease. 

Cerebral  troubles  which  occur  habitually  in  the  later 
periods  of  tabes,  more  especially  general  paralysis  of  the 
insane,  will  be  subsequently  considered. 

14.  Early  symptoms  in  the  sphere  of  sensibility. — Apart 
from  the  lightning-pains  which  have  already  been  described 
(p.  146),  other  symptoms  occur  at  an  early  stage  of  tabes  in 
the  sphere  of  the  sentient  nerves  which  are  highly 
characteristic  of  the  complaint,  and  often  important  in  a 
diagnostic  point  of  view.  These  are  chiefly  hyperaesthesia 
to  touch  or  temperature,  certain  forms  of  parassthesia   in 


200  SCLEROSIS  OF  THE  SPINAL  COED. 

different  parts,  and  numbness  in  the  feet  and  the  peripheral 
branches  of  the  ulnar  nerve. 

a.  Hypercesthesia  may  occur  together  with  occasional 
attacks  of  lightning  pains,  or  exist  by  itself.  The  chief 
feature  of  this  condition  as  seen  in  tabes  is,  that 
simple  touch  of  certain  areas  of  the  skin,  instead  of 
producing  the  ordinary  feeling  of  contact,  is  unpleasant 
and  painful.  This  is  chiefly  seen  in  the  spine  and  its 
neighbourhood,  but  may  also  occur  in  the  lower  extremities, 
and  is  at  a  later  period  of  the  disease  sometimes  followed 
by  anaesthesia  in  the  same  parts. 

Case  59. — A  solicitor,  aged  fifty-five,  married  and  father 
of  six  children,  consulted  me  in  May,  1882.  He  stated  that, 
with  the  exception  of  gonorrhoea  early  in  life,  he  had  never 
been  ill  until  about  eighteen  months  ago,  when  he  began  to 
suffer  from  soreness  and  irritable  feelings  about  the  spine, 
more  especially  between  the  shoulders,  but  also  in  the 
loiELS.  There  was  so  much  tenderness  there  that  he  could 
not  bear  to  be  touched.  The  least  pressure  on  the  vertebrae, 
more  especially  in  the  lower  dorsal  and  upper  lumbar 
region,  was  most  distressing  ;  and  slight  percussion  of 
any  portion  of  the  spine  made  him  wince  and  call  out. 
A  touch  with  a  cold  substance  was  particularly  dis- 
agreeable, while  he  did  not  mind  so  much  anything  hot. 
He  disliked  the  rubbing  of  the  clothes  against  the  back, 
and  could  not  bear  to  have  his  coat  brushed  when  he 
had  it  on  ;  he  could  not  lean  his  back  against  a  chair,  and 
slept  on  his  side  rather  than  the  back.  Any  application  of 
ointments,  embrocations,  etc.,  for  the  relief  of  this  hyper- 
sesthesia  was  particularly  trying  to  him,  and  had  not  done 
him  any  good.  This  hyperaesthesia  was  constant ;  but  the 
patient  also  suffered  from  occasional  attacks  of  shooting 
pains  in  the  arms  and  legs,  and  from  a  sensation  of 
excessive  tightness  round  the  upper  portion  of  the  chest. 
He  never  had  a  headache,  and  there  were  no  symp- 
toms on  the  part  of  the  cranial  nerves.     The   knee-jerk. 


SYMPTOMS  OF  TABES  SPINALIS.  201 

however,  was  completely  lost  in  both  sides,  and  there 
was  undue  excitability  of  the  vastus  internus  to  direct 
percussion.  He  could  walk  fairly  well,  and  the  gait 
showed  no  trace  of  ataxy.  He  had,  however,  a  difficulty  in 
standing  on  one  leg,  and  staggered  when  standing  with  his 
feet  close  together  and  his  eyes  shut.  There  was  no 
anaesthesia  anywhere.  His  digestion  was  fairly  good  ;  but 
he  was  apt  to  vomit  in  the  morning  if  he  had  taken  only  a 
little  more  than  his  usual  allowance  of  wine  the  evening 
before.  The  bladder  was  sluggish.  After  breakfast  he  had 
invariably  a  sudden  involuntary  discharge  of  a  small 
quantity  of  urine — about  two  tablespoonfuls  ;  but  such 
incontinence  did  not  occur  again  during  the  whole  of  the 
day,  and  he  had  never  wetted  the  bed.  The  bowels  were 
regular,  and  under  perfect  control.  The  sexual  desire  and 
power  were  gone  ;  but  he  had  occasionally  seminal  emis- 
sions in  his  sleep,  which  made  him  feel  very  wretched  the 
day  after.  The  patient  was  therefore  evidently  in  the 
first  stage  of  tabes  ;  but  the  hypersesthesia  of  the  spine 
overshadowed  all  the  other  symptoms,  and  was  the  only 
thing  for  which  he  sought  advice. 

b.  Parcssthesia. — Of  all  forms  of  perverted  sensation  which 
occur  in  tabes,  the  most  frequent  and  diagnostically  most 
important  is  a  peculiar  feeling  of  tightness,  constriction,  or 
compression,  which,  from  being  generally  perceived  right 
round  the  chest,  is  also  often  called  belt  or  girdle  sensation. 
The  chest  feels  forcibly  or,  as  some  patients  express  them- 
selves, "fiercely"  compressed  or  constricted,  as  if  a  cord 
or  rope  were  tightly  drawn  around  it,  or  as  if  it  were 
laced  in  stays  of  the  tightest  possible  fit,  or  squeezed 
in  a  vice,  a  press,  or  a  straight-waistcoat.  This  is  one 
of  the  most  uncomfortable  sensations  which  may  be  ima- 
gined, and  often  bitterly  complained  of.  It  causes  diffi- 
culty in  breathing,  and  great  oppression.  When  it  has 
once  taken  hold  of  a  patient,  it  rarely  leaves  him,  and 
continues  year  after  year.      It  is  apt  to  vary  in  degree, 


202  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  when  particularly  severe,  may  take  the  form  of  an  at- 
tack of  asthma,  so  that  the  patient  is  unable  to  lie  in  bed, 
but  is  obliged  to  sit  up  or  lean  forward.  It  is  generally 
worse  at  night.  It  is  also  felt  in  the  lower  part  of  the 
abdomen  and  the  lower  extremities.  In  the  case  of  a 
Parsee  gentleman,  aged  forty  (Case  60),  who  was  sent  to 
me  by  Dr.  Handfield  Jones,  in  December,  1866,  this  was 
the  principal  symptom  complained  of  ;  and  it  was  also 
felt  in  the  legs  and  feet,  which  felt  as  if  they  were  en- 
cased in  excessively  tight  elastic  stockings  or  bandages. 

Miiller,  of  Wiesbaden,  explains  this  curious  symptom 
by  vasomotor  spasm  and  consequent  constriction  of  the 
arterioles  of  the  posterior  columns  ;  but  this  explanation 
is  not  very  satisfactory,  as  vasomotor  spasm  is  rather 
connected  with  a  feeling  of  coldness  and  chilliness  than 
of  tightness.  There  can  be  no  question  that  it  is  owing 
to  sclerotic  irritation  of  the  posterior  root-fibres  ;  but  the 
exact  way  in  which  it  is  produced  is  as  yet  unknown. 

In  exceptional  cases  a  sensation  of  tightness  is  also  felt 
in  the  tongue,  teeth,  face,  and  scalp. 

Other  forms  of  paraesthesia  are  much  less  common.  Oc- 
casionally patients  feel  as  if  drops  of  hot  or  cold  water 
were  falling  on  their  limbs,  or  as  if  large  pailfuls  of  iced 
water  were  poured  over  them,  or  as  if  they  were  knocked 
by  the  fist  or  a  hammer.  One  complains  of  a  sensation  as 
if  there  were  a  tumour  in  the  stomach  ;  another,  as  if  one 
of  his  legs  did  not  belong  to  him,  or  detached  itself  from 
the  body  ;  or  of  a  feeling  of  fulness  or  emptiness  in 
different  parts.  Most  of  these  sensations  are  temporary  ; 
they  may  last  five  or  ten  minutes,  then  disappear,  and 
reappear  at  more  or  less  prolonged  intervals.  * 

c.  Anaesthesia  is  generally  not  very  marked  in  the  first 
stage  of  tabes.  There  may,  however,  be  numbness,  and  a 
feeling  as  if  the  parts  had  gone  asleep,  with  pins  and 
needles  ;  while  actual  loss  of  sensation  is  very  frequent  in 
the  second  period  of  the  disease.    Certain  parts  of  the  body 


SYMPTOMS  OF  TABES  SPINALIS.  203 

are  affected  by  preference,  and  none  more  so  than  the 
soles  of  the  feet,  so  that  the  patient  feels  uncertain  about 
the  nature  of  the  ground  on  which  his  feet  rest  or  move  ;  he 
often  cannot  tell  whether  he  is  standing  on  a  carpeted  floor 
or  a  bare  board  ;  has  a  sensation  as  if  his  boots  were 
padded  inside,  or  as  if  he  were  standing  or  walking  in  the 
snow  or  sand,  or  on  cotton  wool  or  india  rubber,  or  as  if  he 
were  sinking  into  the  ground,  or  as  if  the  latter  rose 
under  his  feet.  He  is  still  able  to  feel  the  prick  of  a  pin, 
and  even  a  simple  touch  by  the  fingers  in  those  parts  ; 
but  this  sensation  is  more  blunt  than  it  is  in  health. 
Plantar  angesthesia  may  be  looked  upon  as  a  symptom  of 
transition,  belonging  to  the  pre-ataxic  as  well  as  to  the 
ataxic  period.  Where  it  is  marked,  ataxy  is  tolerably  sure 
to  follow  presently.  The  soles  of  the  feet,  when  touching 
the  ground,  give  us  a  sensation  of  the  condition  of  the 
ground  on  which  we  walk  or  stand  ;  and  if  this  sensation 
is  absent  or  perverted,  it  is  natural  that  walking  should  be 
difficult. 

In  the  upper  extremities  the  point  of  predilection  is  the 
sphere  of  the  ulnar  nerve,  so  that  numbness  is  experienced 
in  the  third  and  fourth  finger  and  the  corresponding  part 
of  the  hand  and  wrist.  This  may  be  bilateral,  but  is 
usually  confined  to  one  side,  at  a  time  when  both  lower 
extremities  are  already  affected.  It  is  chiefly  inconvenient 
to  musicians,  and  more  especially  to  violin-players. 

Case  61.— In  March,  1874,  Mr.  Jeffery,  of  Worcester, 
asked  me  to  see  a  merchant,  aged  forty-five,  married  and 
childless,  who  had  exceeded  considerably  in  sexual  plea- 
sures, and  had  had  syphilis  nine  years  ago.  He  had  had 
secondary  manifestations  for  about  six  months,  after  which 
they  ceased.  The  patient  remained  well  until  about  two 
years  ago,  when,  apparently  without  any  cause,  he  began  to 
lose  the  control  over  the  bladder,  there  being  incontinence 
of  urine  by  day  as  well  as  by  night.  At  present  he  was 
obliged  to  use   three  napkins   for  the  night,  which  were 


204  SCLEROSIS  OF  THE  SPINAL  CORD. 

thoroughly  saturated  in  the  morning.  At  the  same  time 
that  the  bladder  first  began  to  give  trouble,  the  patient  began 
to  feel  numbness  in,  and  loss  of  control  over,  the  third  and 
fourth  fingers  of  the  left  hand,  which  felt  as  if  he  had  a 
glove  on  ;  and  this  annoyed  him  particularly,  because  his 
chief  pleasure  in  life  was  playing  the  violin,  and  this  was 
very  considerably  interfered  with  by  the  loss  of  sensation. 
The  numbness  after  a  time  spread  right  up  to  the  shoulder- 
blade,  and  in  front  to  the  cardiac  region,  and  thus  affected 
the  left  and  afterwards  the  right  leg.  The  legs  now  feel 
"  as  if  the  feet  were  cut  off  across  the  instep."  He  also 
had  lightning-pains,  more  especially  in  the  left  leg,  and 
sometimes  of  such  awful  severity  as  to  keep  him  awake 
the  whole  night.  The  sexual  power  was  lost,  and  the 
bowels  constipated. 

In  some  cases  we  find  circumscribed  areas  of  the  skin  in 
different  parts  of  the  body  completely  anassthetic,  while 
close  by  all  the  different  forms  of  sensation  are  perfectly 
normal.  Benedict  considers  such  a  symptom  as  a  proof  of 
the  syphilitic  nature  of  the  disease  ;  and  certainly  all  the 
patients  in  whom  I  have  seen  it  had  unmistakably  suffered 
from  constitutional  syphilis. 

Case  62. — In  October,  1882,  Dr.  Mobius,  of  Leipzig,  sent 
a  merchant  to  me,  who  was  thirty-seven  years  of  age, 
married,  and  had  had  two  children.  He  had  had  syphilis 
eight  years  ago,  more  especially  in  the  throat  ;  and  had 
been  insufficiently  treated.  One  of  his  children  has  had 
marked  symptoms  of  congenital  syphilis.  Four  years  ago  he 
began  to  suffer  from  lightning  pains  and  numbness  in  the 
lower  extremities,  and  the  muscles  became  thin  and  flabby. 
There  was  a  degree  of  amblyopia  in  both  eyes,  with  ophthal- 
moscopic signs  of  optic  atrophy.  Westphal's  and  Romberg's 
symptoms  were  present.  The  patient  walked  with  some 
difficulty,  yet  had  only  quite  lately  walked  seven  or  eight 
miles  at  a  stretch,  after  which  he  was,  however,  very  much 
knocked  up.     There  was  habitual  retention  and  occasional 


SYMPTOMS  OF   TABES  SPINALIS.  205 

incontinence  of  the  urine  ;  the  sexual  power  was  much 
diminished,  and  he  felt  very  unwell  after  having  had  con- 
nexion. There  was  an  area  of  complete  ancesthesia  round  the 
the  left  knee,  and  spreading  to  the  upper  portion  of  the  left 
leg  ;  while  in  the  right  knee  and  leg  all  the  different  kinds 
of  sensibility  were  perfectly  normal. 

In  some  patients  there  is  ansesthesia  of  the  penis  at  an 
early  stage  of  the  malady,  when  sexual  power  is  still  pre- 
served. They  may  therefore  have  connexion,  but  have  no 
feeling  of  pleasure  during  the  act.  I  have  seen  the  urethra 
to  participate  in  this  condition,  so  that  the  introduction  of 
the  catheter  was  not  perceived  by  the  patient. 

There  may  be  areas  of  aneesthesia  and  hypersesthesia  of 
considerable  extent  in  the  same  limb  ;  and  more  particularly 
where  tingling  and  pins  and  needles  are  felt  in  the  fingers 
and  toes,  a  degree  of  anaesthesia  is  almost  always  present. 
A  symptom  no  doubt  intimately  connected  with  this  con- 
dition is  that  farado-cutaneous  sensibility  appears  to  be 
very  much  diminished  at  an  early  stage  of  the  malady.  In 
order  to  ascertain  this  a  faradic  soft  wire  brush  is  placed 
on  the  skin,  and  the  minimal  current-strength  which  will 
cause  a  sensation  is  determined,  and  then  compared  with 
healthy  averages  (Erb,  Drosdoff). 

15.  Early  symptoms  in  the  Motor  Sphere. — Loss  of  some 
degree  of  motor  power  is  very  common  in  the  earlier  stages 
of  tabes.  There  is  as  yet  no  sign  of  ataxy,  but  a  feehng 
of  heaviness  and  debihty  in  the  legs,  which  indisposes  the 
patients  to  active  exercise.  They  can  still  walk  apparently 
well,  but  their  legs  do  not  appear  the  same  as  before. 
There  is  a  feeling  of  intense  lassitude.  They  have  a 
difficulty  in  going  upstairs  or  uphill,  get  easily  out  of 
breath,  and  shun  such  exercise  as  going  up  ladders,  or 
standing  on  ladders,  or  crossing  narrow  bridges,  or  dancing, 
or  riding  on  horseback.  This  feeling  of  weakness  varies 
from  time  to  time,  and  occasionally  goes  off  altogether  for  a 
period,  but  is  apt  to  increase  considerably  after  any  particular 


206  SCLEEOSIS  OF  THE  SPINAL  CORD. 

effort  or  expenditure  of  power.  Standing  also  becomes 
difficult  and  fatiguing,  and  is  therefore  avoided  ;  and  even 
at  this  early  period  there  is  a  considerable  increase  in  the 
symptoms  mentioned,  when  the  patient  is  the  dark,  and 
deprived  of  the  aid  of  his  eyes.  He  finds  his  legs  occa- 
sionally giving  way  suddenly,  so  that  he  falls  to  tha 
ground  ;  and  this  may  occur  with  or  without  a  shoot  of 
lio-htning  pain.  There  may  also  be  local  paralysis  of  cer- 
tain groups  of  muscles  ;  such  as  the  adductors  of  the  thigh, 
so  that  there  is  a  difficulty  or  impossibility  to  approach  the 
knees  to  one  another. 

This  symptom  of  exhaustibility  and  lassitude  is  very  con- 
stant, but  has  nevertheless  not  much  diagnostic  importance, 
because  it  also  occurs  in  a  variety  of  other  nervous  affec- 
tions, more  especially  in  neurasthenia.  It  must,  however, 
excite  suspicion  of  tabes,  if  it  is  constantly  experienced. 
In  neurasthenia  there  are  greater  variations  in  the  degree 
of  motor  debility,  while  the  complaint  of  numerous  tabid 
patients  is  that  they  feel  always  exhausted,  morning, 
noon  and  night,  without  any  intervals  whatever. 

16.  Difficulties  of  the  Bladder. — a.  Sluggishness  of  the 
lladder  in  expelling  the  urine  is  a  very  common  symptom 
of  the  earlier  stages  of  tabes.  It  is  apparently  owing 
rather  to  a  certain  degree  of  anaesthesia  in  the  mucous 
membrane  of  the  viscus  than  to  primary  loss  of  power  in 
the  detrusor  muscle.  The  desire  to  urinate  is  not  felt,  and 
the  patient,  therefore,  passes  water  only  once  or  twice  in  the 
twenty-four  hours,  not  because  he  feels  the  want,  but 
because  he  thinks  that  it  is  the  proper  thing  to  do.  In 
consequence  of  this  the  bladder  often  becomes  greatly 
distended  ;  and  this  distension,  in  its  turn,  leads  to  atony  of 
the  muscular  coat  of  the  viscus.  The  stream  is  very  feeble, 
and  often  ceases  before  the  bladder  is  half  emptied.  The 
pressure  of  the  abdominal  parietes  is  called  in  to  aid  the 
efforts  of  the  bladder,  and  flatus  and  faeces  are  occasionally 
expelled  at  a  time  when  the  patient  is  not  prepared  for  such 


SYMPTOMS  OF  TABES  SPINALIS.  207 

an  occurrence.  The  trouble  is  much  greater  when  he  is 
under  the  influence  of  excitement  or  in  a  hurry,  or  when 
other  people  are  present,  as,  for  instance,  in  a  railway  urinal. 
Some  cannot  pass  water  in  the  natural  way,  except  when 
there  is  a  simultaneous  action  of  the  bowels  ;  and  the  aid 
of  the  catheter  is  required  after  a  time. 

Case  63. — In  June,  1883,  I  was  consulted  by  a  merchant, 
aged  54,  married  and  childless,  who  had  had  a  chancre,  fol- 
lowed by  ulceration  in  the  mouth  five  years  ago.  In  1881,  he 
first  began  to  feel  the  vision  in  the  left  eye  to  grow  dim  ;  six 
months  afterwards  the  right  eye  became  similarly  affected. 
At  present  he  is  totally  blind  in  the  left  eye,  while  with  the 
right  he  can  just  make  out  No.  15  (two-line  English)  of 
Jagger's  test-types.  There  is  achromatopsia  ;  the  bladder 
is  so  sluggish  that  the  patient  never  feels  any  desire  to 
empty  it,  and  only  voids  the  urine  once  in  the  twenty-four 
hours,  because  he  considers  it  his  duty  to  do  so.  Although 
this  habit  has  gone  on  for  several  years,  the  urine  showed 
no  signs  of  decomposition ;  it  contained,  however,  an  excess 
of  urea  and  a  sruall  quantity  of  sugar.  There  was  no 
retentiorf  or  incontinence  of  the  urine,  but  the  patient 
spent  about  fifteen  minutes  over  the  act.  At  first  he  had 
to  press  and  strain  for  about  five  minutes  without  anything 
coming  away,  and  then  the  urine  dribbled  away  drop  by 
drop. 

b.  Incontinence  of  the  urine  is  likewise  a  frequent  symp- 
tom in  the  first  stage  of  tabes,  and  much  more  commonly 
met  with  than  retention.  It  may  be  of  a  spasmodic 
or  a  paralytic  character.  If  spasmodic,  a  small  quantity 
of  urine,  varying  from  about  a  teaspoonful  to  two 
tablespoonfuls,  is  suddenly  expelled,  most  frequently  in 
the  morning  after  breakfast,  but  also  at  other  times,  for 
instance,  during  sleep  or  on  first  awaking  in  the  morn- 
ing, or  at  any  time  of  the  day  when  the  bladder  is  full,  and 
a  sudden  movement  or  effort  is  made.  This  form  of  incon- 
tinence, which  in  some  patients   appears   as  regularly  as 


208  SCLEROSIS  OP  THE  SPINAL  CORD. 

clockwork  at  a  stated  hour  of  the  day,  is  entirely  different 
from  the  paralytic  variety  of  incontinence.  The  latter  is 
owing  to  a  degree  of  anaesthesia  of  the  mucous  membrane  of 
the  bladder,  which  is  apt  to  come  on  at  a  somewhat  later 
stage.  The  patient  then  urinates  without  knowing  it,  or 
having  commenced  to  urinate  by  an  effort  of  volition 
has  no  consciousness  of  having  finished,  and  therefore 
continues  to  urinate  into  his  clothes.  Total  inconti- 
nence, where  the  urine  dribbles  away  night  and  day,  is  rare 
in  the  first  stage  of  tabes  ;  but  symptoms  of  catarrh  of  the 
bladder,  with  ammoniacal  decomposition  of  the  urine,  are 
even  then  not  uncommon. 

c.  Vesical  crises  are  amongst  the  most  distressing  pheno- 
mena of  the  disease.  The  patient  may  be  awakened  in  the 
night  by  great  pain  and  irresistible  desire  to  pass  his 
water  ;  there  is,  however,  an  impediment  to  its  passage, 
and  only  a  few  drops  are  passed  at  a  time  by  unheard- 
of  efforts.  The  pain  radiates  from  the  bladder  into  the 
hypogastrium,  the  urethra,  the  perinaeum,  the  groin,  the 
testicles,  and  the  inside  of  the  thighs,  and  may  be  of 
agonising  severity.  Sometimes  a  small  'pellet  of  mucus  is 
thrown  out  from  the  urethra,  with  relief  to  the  pain ;  but 
more  frequently  the  pain  continues  in  paroxysms  for  ten 
or  twelve  hours,  while  the  single  fit  lasts  for  one  or  two 
minutes,  after  which  there  is  a  free  interval  of  a  quarter  of 
an  hour  or  half  an  hour,  and  then  there  is  another  fit.  A 
crisis  may  return  once  a  week  or  so.  Blood  is  occasionally 
passed  at  the  end  of  it,  and  the  patient  imagines  that  he 
must  have  hypertrophy  or  inflammation  of  the  prostate  or 
stone  in  the  bladder.  His  doubts  are  only  set  at  rest  by  a 
careful  exploration  of  the  viscus  ;  but  catheterism  and 
sounding  have  often  a  bad  influence  in  these  cases,  and 
seem  to  lead  to  greater  severity  of  suffering  during  the 
crises. 

The  following  case  was  remarkable  by  the  long  duration 
of  the  attack,  which  lasted  a  week,  and  during  which  the 


SYMPTOMS  OF  TABES  SPINALIS.  209 

patient  had  hardly  any  rest ;    and   also  by  being   compli- 
cated with  gastric  crises  : — 

Case  64. — In  December,  1877,  I  was  consulted  by  a 
merchant,  aged  thirty-two,  married  and  father  of  five 
children.  He  denied  having  ever  suffered  from  gonorrhoea 
or  syphilis  ;  but  he  had  had  rheumatic  fever  seven  years 
ago,  and  has  now  disease  of  the  aortic  valves  with  hyper- 
trophy of  the  left  ventricle.  He  had  masturbated  as  a 
boy,  and  had  been  subject  to  frequent  nocturnal  emissions. 
His  chief  complaint  now  was  of  "  a  horrid  nervousness  "  ; 
and  when  speaking  of  this  to  me,  he  suddenly  burst  out 
crying.  There  was  great  want  of  energy  and  appHcation, 
and  he  easily  became  flurried  on  the  slightest  occasion.  He 
had  frequently  suffered  from  what  he  called  "  rheumatic  " 
pains  in  the  joints  and  back,  more  especially  in  damp 
weather.  These  attacks  have  been  followed  by  numbness, 
which  was  chiefly  marked  in  the  right  side.  The  knee- 
jerk  was  lost  in  both  sides.  The  patient  was  subject  to 
attacks  of  "  dyspepsia,"  with  nausea,  vomiting,  and  flatu- 
lence, and  such  severe  pain  that  he  had  fainted  away  under 
their  influence.  More  lately  he  had  had  attacks  of  irrita- 
bility of  the  bladder,  which  came  on  without  any  apparent 
cause,  lasted  for  a  week,  and  then  disappeared  as  suddenly 
as  they  had  come.  During  such  an  attack  he  had,  by  day 
as  well  as  by  night,  incessant  calls  to  pass  his  urine,  with- 
out being  ever  able  to  pass  more  than  a  few  drops  at  a 
time. 

17.  Intestinal  troubles. — a.  Constipation  of  the  bowels 
is  habitually  complained  of  by  the  tabid  at  an  early  stage 
of  their  malady.  The  muscular  coat  of  the  large  bowel 
is  sluggish,  and  there  is  great  difficulty  in  obtaining  a 
proper  evacuation.  Many  of  our  most  valued  aperients  re- 
fuse service,  and  even  large  purgative  enemata  often  prove 
insuflicient.  In  some  cases  there  is  anaesthesia  of  the 
rectal  mucous  membrane,  so  that  the  contact  of  the  f^ces 
or  the  introduction  of   the  enema-tube  is  not  perceived. 

P 


210  SCLEROSIS  OF  THE  SPINAL  CORD. 

Great  straining  efiorts  may  be  required,  and  the  desire  to 
void  the  contents  of  the  bowels  often  ceases  when  the 
patient  is  ready  to  satisfy  it. 

b.  Diarrhoea  sometimes  alternates  with  constipation, 
and  may  come  on  suddenly,  without  griping  pain  in  the 
abdomen  or  epigastrium,  and  apparently  quite  indepen- 
dently of  the  food  which  may  have  been  taken.  It  may 
last  a  few  hours  or  a  few  days,  disappear  suddenly,  and 
return  after  a  time.  In  the  intervals  the  patients  may 
feel  quite  well,  have  a  clean  tongue,  and  a  good 
appetite.  Occasionally  attacks  of  diarrhoea  coincide  with 
or  follow  bouts  of  lightning  pains.  Where  the  diarrhoea  is 
very  persistent  and  very  profuse,  it  may  ultimately  be- 
come of  a  choleraic  character,  or  be  complicated  with 
haemorrhage  from  the  bowel  ;  and  in  both  cases  a  fatal 
result  is  to  be  feared. 

c.  Intestinal  crises  are  much  rarer  than  gastric  crises, 
but  equally  painful  and  distressing.  They  also  occur  in 
sudden  paroxysms,  there  being  frightful  pain  in  the  inside, 
with  tenesmus,  constant  desire  to  go  to  stool,  spasmodic  and 
painful  contractions  of  the  muscular  coat  of  the  bowel,  and 
mucous,  bihous,  or  serous  diarrhoea.  The  patient  appears 
like  one  in  the  last  stage  of  cholera  ;  the  voice  is  extinct,- 
the  extremities  cold,  the  urine  suppressed,  and  even  cramps 
are  not  wanting.  Alimentation  soon  becomes  difficult  or 
impossible,  and  the  patient  may  die  of  collapse. 

A  special  form  of  the  intestinal  crisis  is  the  rectal  crisis. 

There  is  a  kind  of  anal  neuralgia,  which  may  be  more  or 

less  severe,  with  a  peculiar  feeling  as  if  a  foreign  body 

*  were  forcibly  thrust  high  up  into  the  rectum,  or,  as  some 

patients  express  it,  as  if  they  were  being  impaled. 

d.  Incontinence  of  the  bowel  is  rather  less  frequent  than 
the  analogous  symptom  in  the  bladder.  It  occurs,  however, 
sometimes  at  an  early  stage,  more  especially  when  purgatives 
have  been  taken,  or  after  an  enema.  Sometimes  it  comes 
on  when  the  patient  makes  an  effort  to  urinate,  or  on  laugh- 


SYMPTOMS  OF  TABES  SPINALIS.  211 

ing,  cougliing,  and  sneezing.  As  a  rule  the  discharge  is 
slight,  and  in  some  cases  it  only  occurs  once  or  twice  in 
the  year. 

18.  Sexual  Troubles. — 2^.  Impotence.  In  most  cases  there 
is  early  failure  of  desire  and  of  erectile  power.  Where 
erections  occur,  they  are  evanescent,  occur  on  waking  in 
the  morning,  and  subside  when  the  patient  attempts  to 
utilise  them.  Where  connexion  is  still  possible,  the  act 
is  short,  the  ejaculation  almost  immediate,  and  there  is 
little  or  no  pleasure,  but  great  prostration  afterwards. 
Occasionally  there  is  actual  pain,  or  a  feeling  of  irrita- 
tion, instead  of  pleasure,  at  the  time  of  ejaculation  ; 
while  in  some  cases  the  sexual  power  continues,  more  or 
less  unimpaired,  well  into  the  second  stage  of  tabes. 

Case  66. — In  May,  1884, 1  was  consulted  by  a  gentleman, 
aged  35,  married  and  father  of  five  children,  who  had  con- 
tracted syphilis  in  1868.  The  secondary  symptoms  were 
mild  ;  there  was  a  slight  squamous  rash,  ulcerated  throat, 
and  alopecia.  These  symptoms  were  treated  with  iodide  of 
potassium,  which  he  could  then  take  in  large  doses.  In  1 872, 
while  out  in  the  East,  he  partially  lost  the  sight  of  the 
right  eye  from  optic  atrophy.  In  1875,  thinking  that  he 
was  free  from  the  disease,  he  married.  The  first  child 
was  born  with  a  syphilitic  rash,  and  the  wife  soon  after- 
wards showed  specific  symptoms.  He  now  had  a  course 
of  mercurial  treatment.  In  1876  he  began  to  suffer  from 
neuralgia  in  his  legs,  especially  after  hunting  ;  and  in  1879 
numbness  commenced  in  the  legs,  with  unsteadiness  in 
standing  and  walking.  At  that  time  it  was  first  noticed 
that  the  knee-jerk  was  lost  in  both  sides.  At  present  he  is 
not  much  worse  than  he  was  five  years  ago,  although  rather 
more  unsteady  in  walking.  He  can  walk  half-a-mile  or  more 
with  the  aid  of  a  stick,  the  gait  not  being  very  markedly 
ataxic  ;  but  the  numbness  in  the  legs  and  feet  is  very  great. 
The  bladder  does  not  trouble  him  much,  but  he  has  always 
to  make  water  before  washing  his  hands  ;  if  he  did  not  do 

p  2 


212  SCLEROSIS  OF  THE  SPINAL  CORD. 

SO,  he  would  wet  his  trousers.  The  bowels  are  fairly 
regular  ;  but  if  he  should  take  any  purgative  medicine,  or 
if  the  bowels  become  relaxed  from  any  other  cause,  he  must 
obey  the  call  at  once,  or  there  would  be  involuntary  dis- 
charge. He  also  has  frequently  feelings  of  fulness  in  the 
rectum,  which  come  on  for  a  few  minutes  and  then  pass  off. 
The  sexual  desire  is  as  good  as  ever ;  his  last  child  is  only  a 
few  months  old,  and  even  she  had  a  slight  specific  rash 
when  she  was  born,  showing  that  the  patient  had  not  yet 
got  rid  of  the  venereal  poison. 

b.  Satyriasis  is  rare,  but  occasionally  occurs  quite  in  the 
beginning.  Painful  spasmodic  erections  occur  frequently, 
when  they  are  not  wanted,  at  any  time  during  the  day,  and 
are  very  persistent  during  sleep.  The  penis  is  of  stony 
hardness,  and  the  erection  continues  so  long  that  it  becomes 
intensely  painful.  The  parts  are  in  such  a  state  of 
hyperaesthesia  and  undue  excitability  that  the  patient  dreads 
to  have  a  motion  or  to  pass  his  urine.  A  sudden  noise, 
the  vibration  caused  by  riding  in  a  carriage,  some  slight 
exertion,  or  excitement  of  any  kind  will  sometimes  start  the 
erection,  and  produce  the  feeling  of  an  impending  emission. 
The  whole  nervous  system  may  then  gradually  be  brought 
into  a  state  of  extreme  hyperaesthesia  and  weakness, 
rendering  the  patient  more  or  less  incapable  of  mental 
as  well  as  physical  exertion.  There  is  generally  an 
aching  pain  in  the  loins  and  the  testicles  ;  incontinence 
of  urine  is  commonly  present;  and  gastric  and  vesical 
crises  may  add  to  the  troubles  of  the  patient,  who 
is  then  in  a  truly  deplorable  condition.  Occasionally, 
in  order  to  free  himself  from  such  troubles,  a  man  will 
under  these  circumstances  accomplish  connexion  six 
or  seven  times  in  a  couple  of  hours,  and  repeat  such  a 
performance  day  by  day.  It  is  then  often  believed  that  he 
is  particularly  well  and  strong  ;  but  this  condition  lasts 
rarely  longer  than  a  few  months,  and  is  then  followed  by 
complete  anaphrodisia.     Eisenmann  has,  however,  seen  a 


SYMPTOMS  OF  TABES  SPINALIS.  213 

case  where  satyriasis  continued  more   or  less  strongly  for  a 
space  of  thirty  years. 

In  my  experience  patients  in  whom  satyriasis  has  been 
an  early  symptom  of  tabes  have  had  naturally  strong 
sexual  instincts,  and  been  addicted  to  masturbation  early 
in  childhood,  as  well  as  later  in  life,  and  to  indis- 
criminate sexual  intercourse  from  an  early  age.  The 
sexual  passion  seems  to  be  the  great  ruler  of  their  Hfe  ; 
and  when  it  has  once  led  them  into  syphilis,  tabes  is 
apt  to  become  developed. 

c.  Nymphomania  in  women  appears  to  be  rare.  Some- 
times, however,  they  appear,  more  especially  during 
periods  of  lightning  pains,  subject  to  lustful  sensations, 
and  abundant  secretion  from  the  vulva,  vaginal  and 
uterus.  Menstruation  is  generally  not  much  affected,  but 
continues  regular  up  to  an  advanced  period  of  the 
disease. 

d.  Spermatorrhoea  is  not  very  common,  and  likewise 
occurs  chiefly  in  persons  who  have  exceeded  much  in 
venereal  pleasures.  They  are  liable  to  frequent  noc- 
turnal emissions,  with  or  without  lascivious  dreams  ;  and 
also  to  ejaculation  of  seminal  and  prostatic  fluid  in  the 
daytime,  with  or  without  erections.  The  mental  depres- 
sion which  is  consecutive  upon  this  state  of  things  is 
quite  out  of  proportion  to  the  loss  of  substance  which 
the  patients  experience,  and  is  often  considerably  pro- 
moted by  reading  quack  publications. 

e.  Finally  aspermatism  may  occur  in  the  first  stage  of 
tabes.  This  condition  is  generally  accompanied  by  mal- 
nutrition or  actual  wasting  of  the  testicles. 

19.  Perforating  Ulcer  of  the  Foot.  —  There  are  several 
varieties  of  this  affection,  which  may  be  either  a  local 
disease  or  a  symptom  of  a  more  general  malady.  Thus  it 
may  come  on  from  suppuration  of  a  bursa  beneath  a  corn, 
when  it  may  be  supposed  to  be  entirely  local  in  its  origin. 
Such  cases  may  get  perfectly  well  under  surgical  care,  and 


214  SCLEROSIS  OF  THE  SPINAL  CORD. 

the  patient  may  never  develop  other  symptoms.  Southam^ 
has  recorded  a  case  where  the  patient  had  a  perforating 
ulcer  on  the  outer  aspect  of  the  phalangeal  joint  of  the 
great  toe,  which  had  commenced  with  suppuration  beneath 
a  corn.  Amputation  of  the  toe  was  performed  at  the 
metatarso-phalangeal  joint  ;  the  patient  got  well,  and 
never  had  an  ache  or  pain  afterwards. 

Perforating  ulcer  has  also  been  seen  after  compression  of, 
or  injury  to,  the  sciatic  nerve,  but  is  more  especially  found 
in  connection  with  tabes,  of  which  it  may  be  the  first  or 
one  of  the  first  symptoms.  In  this  latter  case,  it  is  almost 
invariably  symmetrical  in  both  feet ;  or,  if  there  is  an  ulcer 
in  only  one  foot,  there  is  at  least  a  hard  callosity  in  the 
corresponding  part  of  the  other,  which  may  in  course  of 
time  develop  into  an  ulcer.  It  is  frequently  followed,  and 
sometimes  preceded,  by  lightning-pains,  gastric  crises,  and 
palsies  of  ocular  muscles. 

The  following  is  an  instance  of  perforating  ulcer  being 
apparently  the  first  symptom  of  tabes  : — 

Case  66. — In  May,  1884,  the  secretary  of  the  Amalga- 
mated Society  of  Carpenters  and  Joiners  asked  me  to 
examine  one  of  their  members,  who  was  thirty-eight  years 
of  age,  married  and  father  of  two  children.  Four  years 
ago,  after  having  worked  much  in  damp  shops,  and  stand- 
ing a  good  deal  on  the  bare  ground,  this  man  found  a  painful 
soreness  commencing  in  both  soles  of  the  feet,  which  gra- 
dually turned  into  perforating  ulcer.  He  was  admitted  into 
the  Middlesex  Hospital,  and  gradually  began  to  improve, 
but  never  got  thoroughly  well.  Even  now  he  has  a  deep 
circular  sore,  as  large  as  a  sixpence,  in  the  centre  of  each 
sole,  surrounded  by  an  area  of  thickened  skin,  and  complete 
aneesthesia  and  analgesia,  while  at  the  edge  of  the  foot 
sensation  is  perfectly  normal.  In  walking,  he  has  lately, 
had  a  sensation  as  if  he  walked  on  a  carpet.  About  twelve 
months  ago  he  noticed  that  he  could  not  stand  well  when 
1  "  British  Medical  Journal,"  June  23,  1883. 


SYMPTOMS  OF  TABES  SPINALIS.  215 

washing  himself  in  the  morning,  and  that  he  felt  giddy, 
and  had  to  look  to  his  feet  to  prevent  himself  from  falling. 
This  trouble  has  increased  of  late.  He  now  complains  of 
tightness  in  the  chest  and  difficulty  in  breathing.  The 
knee-jerk  is  completely  lost  on  both  sides,  but  the  excit- 
ability of  the  quadriceps  femoris  to  direct  percussion  is  not 
increased.  Ataxy  in  the  lower  extremities  is  marked.  He 
has  had  no  symptoms  on  the  part  of  the  bladder,  bowel, 
or  sexual  organs,  nor  higher  up  than  the  waist.  He 
denied  having  ever  suffered  from  syphihs,  had  had  no 
accident,  and  never  over-exerted  himself  in  walking  or 
otherwise. 

It  would  be   difficult  to  determine  whether  in  this  case 
the  cause  of  the  ulcers  was  peripheral  neuritis,  although 
the  ansesthesia  and  analgesia  round  the   sores  made  this 
probable.     There  could,  however,  be  no  doubt  at  all  about 
the  existence  of  tabes  at  the   time  when  I  examined  the 
patient ;  and  it  would  require  a  great  stretch  of  imagination 
to  suppose,  with  Page,  that  in  such  a  case  as  this  a  corn 
led  to  the  ulcer,  and  the  ulcer  to  tabes.     It  is  much  more 
likely  that  the  influence  of  wet  and  cold,  by  the  patient 
standing  much  on  the  bare  ground,  led  first  to  the  spinal 
affection,  and  that  the  perforating  ulcer  was  one  of  the 
first,  if  not  actually  the  first,  symptom  of  tabes  ;  and  that, 
in  the  natural  evolution  of  the  disease,  the  other  symptoms 
which  have  just  been  mentioned  made  their  appearance. 
Unfortunately,  it  is  generally  impossible    in    these  cases 
to  find  out  at  what  period  of  the  illness  the  knee-jerk  was 
lost  ;  for  practitioners  and  operating  surgeons  are  still  very 
far  from  having  realised  the  immense  practical  value  and 
diagnostic  importance  of  this  symptom. 

In  other  cases,  the  ulcer  may  appear  some  time  after 
definite  symptoms  of  tabes  have  already  shown  themselves. 
Ball  and  Thibierge,  Hanot,  Treves,  Fayard,  Duplay,  Morat, 
and  many  other  surgeons  have  recorded  examples  of  this 
affection.     Such  ulcers  may  heal,  while  at  the  same  time 


216  SCLEROSIS  OF  THE  SPINAL  CORD. 

the  spinal  disease  may  be  progressing  ;  but  relapses  are 
exceedingly  common  as  soon  as  the  patient  leaves  the  hori- 
zontal position  and  returns  to  work. 

20.  Arthropathies  and  other  Tro^jhic  Affections.  —  The 
peculiar  joint-affection  which  Charcot  was  the  first  to  de- 
scribe (p.  35),  may  come  on  in  the  first  stage  of  tabes,  and 
may  indeed  be,  if  not  the  first,  at  least  one  of  the  first 
symptoms  of  it  ;  but  it  is,  perhaps,  on  the  whole  more  fre- 
quent in  the  commencement  of  the  second  stage,  when  the 
symptoms  of  ataxy  begin  to  become  developed.  Volkmann 
has  endeavoured  to  account  for  the  origin  of  this  joint- 
affection  by  the  ataxic  movements  of  the  patient  producing 
shocks  to  the  inner  surfaces  of  the  joints,  and  contusion  of 
the  ligaments  and  capsules  ;  but  this  explanation  is  contro- 
verted by  the  simple  fact  that  arthropathy  may  occur  before 
any  ataxy  exists.  It  seems  probable  that  arthropathy  is 
owing  to  that  form  of  peripheral  neuritis  which  is  known 
to  accompany  not  unfrequently  certain  diseases  of  the 
centres  of  the  nervous  system. 

Arthropathy  is  not  uncommon,  for  Charcot  has  found  it 
in  one  out  of  ten  cases  of  tabes  ;  and,  since  he  directed 
attention  to  it,  it  has  been  not  unfrequently  seen  by  other 
observers.  It  seems  to  affect  chiefly  the  large  joints,  more 
particularly  the  knee,  shoulder,  elbow,  hip,  and  wrist,  in 
the  order  in  which  they  have  just  been  mentioned,  while 
the  smaller  joints  of  the  carpus  and  metacarpus,  and  tarsus 
and  metatarsus,  etc.,  are  more  rarely  involved. 

The  first  symptom  is  generally  a  swelling,  which  may  or 
may  not  be  preceded  by  crepitation.  G-reat  rarefaction  and 
atrophy  of  osseous  tissue,  and  more  especially  of  the  arti- 
cular ends  of  the  bone,  has,  however,  preceded  this  for  a 
more  or  less  considerable  time.  The  initial  crepitation  is 
evidently  caused  by  the  separation  of  small  pieces  of  bone, 
which  break  through  the  capsule,  and  thereby  make  a  path 
for  the  synovia.  This  latter  is  effused  into  the  cellular 
tissue  of  the  limb,  and  thereby  causes  the  swelling.     The 


SYMPTOMS  OF  TABES  SPINALIS.  217 

skin  over  the  swelling  is  hard  and  resisting,  and  there  is  no 
pitting  on  pressure.  The  swelling  may  reach  its  maximum 
within  a  few  hours,  and  loose  bodies  of  the  size  of  peas  or 
filberts  may  float  in  the  hquid.  Dreschfeld^  has  found  a 
mass  of  bone  more  than  an  inch  long  in  the  sheath  of  the 
sartorius  muscle,  and  moving  about  freely  with  the  con- 
traction of  the  muscle.  There  is  no  pain,  either  spontaneous 
or  on  moving  the  limb,  or  manipulating  it,  showing  absence 
of  inflammation  ;  and  the  only  trouble  which  the  patient 
experiences  is  caused  by  the  mechanical  distension  of  the 
limb  through  the  swelling.  There  are  no  symptoms  deno- 
ting any  general  disturbance  of  the  system  or  any  local 
reaction  ;  but  lightning-pains  have  often  been  found  to 
precede  the  first  symptoms  of  the  arthropathy. 

I  have  already  mentioned  that  we  distinguish  between  a 
benign  and  malignant  arthropathy  (p.  35).  In  the  former 
the  swelling  may  become  dispersed  in  a  short  time,  viz., 
from  two  to  ten  days  ;  while  in  the  latter  the  symptoms 
may  continue  for  an  indefinite  period,  and  lead  eventually 
to  irreparable  disorganisation  of  the  joints,  hypertrophy,  or 
more  frequently  atrophy  of  the  epiphyses,  absorption  of 
bone,  and  complete  or  incomplete  dislocation. 

If  the  hip-joint  is  affected,  the  head  of  the  femur  under- 
goes spontaneous  dislocation.  It  leaves  the  cotyloid  cavity, 
and  enters  the  external  iliac  fossa,  causing  the  leg  to 
become  three  or  four  inches  shorter.  The  head  and  neck 
of  the  thigh-bone  are  gradually  entirely  destroyed,  the  aceta- 
bulum is  depressed  and  partly  wasted,  and  the  cartilages 
are  likewise  destroyed.  The  head  of  the  femur  may  be  felt 
as  a  distinct  projection  under  the  skin  ;  it  is  freely  movable 
and  may  be  easily  reduced,  but  soon  slips  out  again  from 
the  acetabulum.  If  the  knee  suffers,  it  may  be  gradually 
dislocated  backwards,  so  that  the  upper  surface  of  the 
tibia  is  felt  under  the  skin.  The  patient  may  at  first  still 
be  able  to  go  about,  as  the  swelling  is  painless  ;  then  the 
»  "The  Lancet,"  July  10,  1880. 


218  SCLEROSIS  OF  THE  SPINAL  CORD. 

leg  suddenly  gives  way,  the  knee  appears  dislocated,  and 
the  patella  is  pushed  inwards. 

If  the  lesion  is  more  in  the  shaft  of  the  bone,  spontaneous 
fracture  may  be  the  result,  such  as  we  see  it  in  paralysed 
and  insane  persons,  where  there  is  abnormal  fragility  of 
the  bones. 

Arthropathy  occurs  not  only  in  tabes,  but  after  injury  to 
peripheral  nerves,  where  Weir  Mitchell  has  seen  it  together 
with  herpes,  glossy  skin,  rapid  muscular  atrophy,  etc.  It  is 
occasionally  seen  in  hemiplegia  from  cerebral  haemorrhage 
or  softening  ;  and  in  other  diseases  of  the  cord,  such  as 
acute  myelitis,  tumour  of  the  grey  matter,  paraplegia  from 
Pott's  disease,  and  hemiparaplegia  from  injury  to  the  cord. 

Nutritive  disturbances,  which  are  intimately  connected 
with  tabes,  occur  in  other  parts  besides  the  joints.  The 
skin  is  generally  dry  and  cold,  and  subject  to  eruptions,  such 
as  herpes,  pemphigus,  and  ichthyosis.  Buzzard  has  re- 
corded the  case  of  a  man  who  had  more  than  two  hundred 
attacks  of  herpes  in  the  course  of  twenty  years.  Other 
observers  have  seen  pemphigus,  appearing  in  the  legs,  after 
attacks  of  lightning  pain,  the  bullae  varying  in  size  from 
that  of  a  lentil  to  a  crown  piece,  and  fading  away  again 
in  five  or  six  days.  Erythema,  lichen,  eczema,  and  urti- 
caria are  also  occasionally  seen.  Er.chymoses,  or  small 
hsemorrhages  in  the  skin  are  not  infrequent.  These 
effusions  gradually  undergo  the  usual  changes,  and  dis- 
appear in  about  a  week,  without  leaving  any  further 
traces.  They  are  seen  after  painful  attacks  in  those 
limbs  which  have  particularly  suffered.  Itching  is  some- 
times so  violent  that  the  patients  dislike  it  as  much  as  a 
gastric  crisis.  An  eruption  resembling  ichthyosis  has  been 
seen  by  Ballet  and  Dutil,  occupying  nearly  the  whole  body. 
It  was  slowly  developed,  and  appeared  chiefly  in  places 
which  had  previously  been  subject  to  anaesthesia,  hyper- 
aesthesia,  or  lightning  pains.  The  skin  was  dry,  thickened, 
livid,  and  in  a  state  of  constant  desquamation.     The  upper 


SYMPTOMS  OF  TABES  SPINALIS.  219 

extremities  are  particularly  liable  to  this  affection,  and  the 
back  of  the  hand  is  sometimes  so  disfigured  as  to  resemble 
pellagra. 

The  nails  are  also  subject  to  malnutrition,  especially 
those  of  the  big  toes.  The  nail  first  becomes  black,  as  if 
it  were  suffused  with  blood,  and  after  a  time  is  found  to  be 
loose,  and  falls  off.  The  matrix  and  skin  in  the  neigh- 
bourhood may  be  anaesthetic  or  hyper^sthetic  ;  and  there 
may  be  a  dull,  continuous  aching  in  the  toes,  which  is  in- 
creased by  pressure.  The  nail,  however,  falls  off  without 
suppuration,  after  which  the  pain  is  relieved ;  and  it  seems 
to  grow  again  quickly ;  the  reproduced  nail  may  be  nor- 
mal or  deformed,  but  appears  mostly  thickened,  raised, 
crumpled,  marked  by  longitudinal  or  transverse  furrows, 
hard,  and  without  its  normal  transparency.  Sometimes  the 
nail  of  the  little  toe  is  affected  in  a  similar  manner,  but 
this  kind  of  dystrophy  is  not  seen  in  the  finger-nails. 
Nails  sometimes  fall  off  but  once  a  year ;  and  the  same  may 
occur  in  cases  of  insular  sclerosis,  and  hemiplegia  from 
vascular  lesions  of  the  brain. 

The  teeth  may  likewise  fall  out  spontaneously,  more 
especially  where  lightning-pains  have  occurred  in  the  face, 
and  where  there  have  been  laryngeal  and  gastric  crises. 
In  a  case  recorded  by  Demange,  where  this  had  occurred 
together  with  anaesthesia  of  the  skin  and  the  mucous 
membranes  of  the  face,  and  with  loss  of  taste,  inspection 
showed  some  years  afterwards  all  the  nuclei  on  the  floor  of 
the  fourth  ventricle  to  be  sclerosed,  and  the  trunks  of  both 
fifth  nerves  contained  numerous  sclerosed  fibres.  In  another 
case,  where  there  had  been  ansesthesia  in  the  sphere  of  the 
left  fifth  nerve,  with  falling-out  of  teeth  from  the  left 
upper  jaw,  the  autopsy  showed  sclerosis  of  both  fifth  nerves, 
the  left  being  changed  into  a  grey  gelatinous  thread,  which 
was  hardly  recognisable.  The  Gasserian  ganglion  was 
reduced  to  a  flat  bit  of  connective  tissue,  and  sclerosis  of 
nerve-nuclei  was  found  in  the  fourth  ventricle. 


220  SCLEROSIS  OP  THE  SPINAL  CORD. 

The  occurrence  of  muscular  atrophy,  owing  to  propaga- 
tion of  the  disease  to  the  anterior  cornua  of  the  spinal  cord, 
has  already  been  mentioned  (p.  23)  ;  and  cases  have  been 
given  (pp.  106, 108)  in  which  this  was  observed  during  life. 
With  the  exception  of  the  muscular  wasting,  all  the  other 
forms  of  nutritive  disturbance  are  probably  owing  to  local 
nerve-lesions  rather  than  to  disease  of  any  portion  of  the 
spinal  cord  itself. 

21.  Vasomotor  Symptoms. — Signs  that  the  vasomotor  or 
sympathetic  system  of  nerves  is  suffering  in  tabes  are  not 
wanting.  A  very  common  complaint  of  patients  is  a  feeling 
of  cold  and  chill,  more  especially  in  the  feet  and  legs, 
which  may  be  owing  to  spasm  of  the  vasomotor  system,  or 
to  loss  of  excitability  in  the  vaso-dilator  nerves.  In  such 
cases  friction,  or  faradisation  of  the  skin  by  a  powerful  cur- 
rent applied  with  a  wire  brush,  does  not  cause  any  redden- 
ing of  the  skin,  or  at  most  a  slight  degree  of  it. 

Hyperidrosis  is  occasionally  seen  in  the  palms  of  the 
hands  and  the  soles  of  the  feet,  and  is  sometimes  accom- 
panied by  seborrhoea  of  the  scalp.  Ebstein  has  seen 
unilateral  sweating,  with  disease  of  the  sympathetic  gan- 
glia on  the  affected  side  of  the  body  only.  This  agrees 
with  an  observation  of  Bernard's,  that  after  section  of  the 
sympathetic  nerve  in  horses,  there  was  sweating  on  the 
affected  side,  which  he  ascribed  to  temporary  paralysis  of 
the  ganglionic  cells.  E-emak  has  recorded  a  case  of 
hyperidrosis  in  the  face,  head,  and  armpit  on  one  side,  which 
was  increased  if  the  patient  partook  of  condiments,  such 
as  mustard,  vinegar,  etc.;  there  being  also  unilateral  myosis, 
and  increased  temperature  in  the  external  meatus.  On  the 
other  hand,  there  may  be  amd?'osis,  or  total  suppression  of 
perspiration.  Putnam  ^  has  described  a  case  where  a  patient 
perspired  in  the  upper  portion  of  the  body,  but  not  anywhere 
below  the  umbilicus.     Injection  of   five  milligrammes  of 

1  "  Eecherches  sur  les  troubles  fonctionnels  des  nerfs  vasomoteurs 
dans  revolution  du  tabes  sensitif."     Paris,  1882. 


SYMPTOMS  OF  TABES  SPINALIS.  221 

pilocarpine  caused  the  upper  part  of  the  body  to  perspire 
profusely,  while  the  lower  portion  remained  quite  dry.  On 
another  occasion  the  dose  of  pilocarpine  was  increased  to 
a  centigramme  ;  after  which  the  upper  part  of  the  body 
perspired  more  profusely,  the  abdomen  very  slightly,  the 
thighs  just  a  little,  while  the  legs  and  feet  remained  per- 
fectly dry.  In  two  other  patients  in  the  hospital,  in 
whom  the  same  dose  was  injected  at  the  same  time,  per- 
spiration in  the  lower  limbs  was  quite  as  profuse  as  in  the 
other  parts. 

The  same  observer  has  noticed  sialorrhoea  in  two  cases 
of  tabes.  There  was  suddenly  during  sleep  an  abundant 
flow  of  saliva,  which  in  one  patient  ran  from  his  mouth 
like  a  stream  ;  the  attack  lasted  about  a  quarter  of  an  hour, 
and  the  quantity  of  saliva  discharged  on  that  occasion 
amounted  to  about  sixteen  ounces. 

Whether  there  is  2iJi.j  gastrorrhoea,  apart  from  gastric  crises, 
does  not  seem  quite  certain.  Occasionally  no  doubt,  the 
vomiting  of  large  quantities  of  water,  amounting  to  ten  or 
twelve  quarts  in  a  short  time,  is  almost  the  only  symptom 
of  an  attack  ;  but  the  sudden  onset  and  the  equally  sudden 
cessation  of  it,  apparently  without  being  influenced  by 
treatment,  resemble  very  much  what  takes  place  in  a 
gastric  crisis. 

The  same  considerations  apply  to  attacks  of  diarrhoea, 
which  have  already  been  mentioned  (p.  210),  and  which 
are  probably  owing  to  sudden  loss  of  power  in  the  in- 
ferior mesenteric  plexus  of  the  sympathetic  system  of 
nerves. 

***** 

Such  are  the  symptoms  which  do  or  may  occur  in  the 
first  stage  of  tabes  spinalis  ;  and  it  is  impossible  not  to  be 
struck  by  the  extraordinary  variety  which  they  manifest. 
There  is  no  other  disease  in  the  whole  range  of  pathology 
which  may  commence  in  such  extremely   different  ways 


222  SCLEROSIS  OF  THE  SPINAL  CORD. 

as  tabes;  and  it  is  undoubtedly  this  circumstance  which  ac- 
counts for  the  mistakes  which  have  been  and  are  even  now 
so  frequently  made  in  the  diagnosis  of  the  earlier  stages  of 
that  disease.  Thus  we  may  at  the  same  time  have  a  num- 
ber of  patients  under  our  care  who  are  all  in  the  first  stage 
of  tabes,  and  who  have  yet  hardly  a  single  symptom  in  com- 
mon with  the  only  exception  of  the  loss  of  the  knee-jerk. 
One  of  them  may  complain  of  loss  of  sexual  power  ;  an- 
otlier,  of  hypersesthesia  in  the  back  ;  a  third,  of  indigestion 
and  a  sensation  of  tightness  round  the  stomach  ;  a  fourth, 
of  rheumatic  or  neuralgic  pains  ;  a  fifth,  of  failure  of  sight, 
and  inability  to  lift  the  eyelid  ;  a  sixth  of  a  feeling  of  in- 
tense lassitude  in  walking,  and  so  on.  This  shows  the 
great  importance  of  being  intimately  acquainted  with  all 
the  truly  protean  forms  which  this  extraordinary  malady 
may  assume — an  importance  which  is  by  no  means  only 
theoretical,  but  chiefly  practical  ;  for  it  is  in  the  first  stage 
of  tabes  that  our  therapeutical  efforts  are  more  likely  to  be 
crowned  with  success  than  at  any  later  period  in  the  evolu- 
tion of  the  disease. 


II.  Symptoms  of  the    Second  or  Ataxic  Stage    of  Tabes 

Spinalis. The  second  stage  of  tabes  is  occasionally  ushered 

in  by  fever.  The  patient  feels  chilly,  and  afterwards  hot  ; 
the  temperature  rises  to  100°  or  101°  ;  the  pulse  beats  at 
100  to  140  ;  there  is  great  lassitude,  loss  of  appetite,  a 
coated  tongue,  and  constipation  of  the  bowels.  A  feeling 
of  fulness  in  the  head,  with  vertigo,  and  sometimes  tinnitus, 
is  complained  of  ;  lightning  pains,  which  may  have  been 
dormant  for  some  time,  are  apt  to  revive,  and  considerable 
hypersesthesia  may  exist  in  the  back.  Tingling  and  '*pins 
and  needles  "  are  felt  in  the  limbs;  and  there  is  often  consider- 
able mental  depression,  with  a  sense  of  impending  danger. 
These  symptoms  generally  last  only  two  or  three  days,  or 
at  most  a  week  ;  but  if  the  patient  is  then  again  carefully 


SYMPTOMS  OF  TABES  SPINALIS.  223 

examined,  he  is  found  to  be  in  a  worse  condition  than  he 
was  before  the  attack.  Febrile  movements  of  this  kind 
may  occur  several  times  in  the  course  of  the  disease,  and 
always  point  to  an  increased  activity  of  the  morbid  process, 
and  mark  another  step  in  the  downward  career  of  the 
patient. 

The  principal  new  symptom  which  now  appears,  and 
which  imparts  an  entirely  new  aspect  to  the  malady,  is  that 
of  ataxy.  From  this  time  forward,  the  ataxy  overshadows 
more  or  less  all  the  other  symptoms  of  the  disease,  with  the 
result  that  patients  in  the  second  stage  of  tabes  resemble 
one  another  a  great  deal  more  than  in  the  first.  The  extreme 
differences  which  we  have  seen  to  exist  in  the  pre-ataxic 
stage  begin  now  gradually  to  fade  away,  and  the  diagnosis 
is  rendered  proportionately  easier. 

22.  Ataxy. ^ — The  first  who  drew  a  distinction  between 
ataxy  and  paralysis  was  Todd,^  who  stated  that  two  kinds 
of  paralysis  might  be  noticed  in  the  lower  extremities,  — the 
one  consisting  simply  of  the  impairment  or  loss  of  voluntary 
motion,  the  other  distinguished  by  a  diminution  or  total 
absence  of  the  power  of  co-ordinating  movements.  In  the 
latter  form,  while  considerable  muscular  power  remained, 
the  patient  found  great  difficulty  in  walking,  and  the  gait 
was  so  tottering  and  uncertain  that  his  centre  of  gravity 
was  easily  displaced.  In  these  few  words  we  have  a  good 
description  of  the  symptoms  of  ataxy  or  asynergy,  as 
generally  observed  in  the  second  stage  of  tabes  spinalis. 
The  term  "  ataxy  "  is  as  old  as  that  of  tabes,  for  both 
originate  with  Hippocrates,  and  both  have  entirely  changed 
their  meaning  in  the  course  of  time.  By  tabes  dorsalis 
the  Father  of  Medicine  understood  a  disease  arisino-  from 
sexual  excesses,  the  chief  symptoms  being  spermatorrhoea, 
marasmus,  and  hectic  fever.     The  term  ataxy,  on  the  other 

'  From  rd^ig,  order,  and  privative  Alpha  (want  of  order) . 
^  *' Cyclopasdia   of   Anatomy   and   Physiology,"    vol.   iii.,    p.    721. 
London,  1847. 


224  SCLEROSIS  OF  THE  SPINAL  CORD. 

hand,  was  used  somewhat  indiscriminately  for  chorea,  fevers, 
and  various  nervous   disorders.     At  present,  however,  we 
understand  by  ataxy,  not  a  disease  of  itself,  but  merely  this 
special  symptom,  which   consists  of  a  want  of  co-ordination 
of  complex  voluntary  movements,  and  a  tendency  on  the 
part  of  the  patient  to  lose  his  balance,  but  without  actual  loss 
of  power,   and  apart  from   tremor,  chorea,  and  paralysis. 
This  symptom  may  be  seen  in  disease  of  the  cerebellum, 
and  in  alcoholic,  saturnine  and  mercurial  poisoning  ;  but  it  is 
more  especially  connected  with  that  disease  which  has  been 
long  familiar  to  us  as  tabes.     The  first  good  clinical  study 
of  this  symptom  we  owe  to  Duchenne,  who  gave  a  more 
minute  analysis   of    what  really   constitutes   co-ordination 
than  any  previous  observer.    He  first  drew  a  clear  distinction 
between  the   different  kinds  of  muscular  action,  viz.,  the 
executive  and  the  controlling  power  ;  and  taught  that  in 
all  voluntary  movements,  which  we  habitually  carry  out  in 
life,  there  is  not  simply  action,   but  also   tempering  and 
regulating  of  action    by  the  antagonistic  muscles.    With- 
out such  mutual  co-operation  of  different  sets  of  muscles, 
movements  would  become  devoid  of  certainty  and  precision^ 
and  would  be  more  brisk  and  excessive  than   is  necessary 
for  the    purpose   which   they    intend   to   serve.     Isolated 
muscular  movements  may  be  obtained  by  artificial  means, 
such   as  faradisation,    but  do   not  occur    in   our  common 
actions   of  every-day  life.     Complex  muscular  actions  are 
learned  early  in  life  by  incessant  practice,  and  become  in 
the  adult  automatic,  so  as  to  be  carried  out  without  an  effort 
of  volition.     The  loss  of  this  slowly  acquired  faculty  of 
co-ordination  is  therefore  what  we  now  understand  by  the 
term,  ataxy. 

Ataxy  is  apt  to  come  on  about  four  or  five  years  after 
the  first  symptoms  of  tabes,  such  as  palsies  of  ocular 
muscles,  lightning  pains,  amblyopia,  etc.,  etc.,  have  made 
their  appearance.  In  some  cases,  however,  the  ataxic  stage 
is  never  reached,  as  the  patients  die  previously  of  gastric 


SYMPTOMS  OF  TABES  SPINALIS.  225 

and  intestinal  crises,  collapse,  bronchitis,  and  diarrhoea. 
In  others,  again,  the  pre-ataxic  stage  may  last  twenty  years 
and  longer  before  the  second  stage  is  entered  upon.  In 
the  majority  of  cases  the  symptom  of  ataxy  is  slowly 
developed  ;  but  in  a  few  it  supervenes  suddenly,  more 
especially  after  over-exertion  or  severe  exposure  to  cold. 

In  most  cases  which  come  under  our  care,  we  may  dis- 
tinguish three  different  epochs  or  periods  of  ataxy.  Such 
a  distinction  has  not  hitherto  been  made,  but  I  believe 
that  it  will  be  found  to  considerably  facilitate  the  study 
and  comprehension  of  the  different  aspects  which  this  im- 
portant symptom  is  apt  to  assume  at  different  times  in  the 
progress  of  the  disease.  These  periods  I  will  characterise 
as  follows  : — 

1st.  The  initial  period,  in  which  ataxy  is  so  sHghtly 
marked  that  a  skilled  exploration  is  required  in  order  to 
discover  the  symptom ; 

2nd.  The  truly  ataxic  period,  in  which  the  peculiar  walk 
known  as  the  "  ataxic  gait "  is  observed  ;  and 

3rd.  The  period  of  muscular  madness,  in  which  even  the 
typical  ataxic  gait  is  no  longer  possible,  and  muscular 
action,  as  far  as  it  still  exists,  is  in  absolute  confusion. 

A.  The  Initial  Period. — It  is  difficult  to  say  exactly 
when  the  ataxy  of  movements  commences,  as  the  transition 
from  the  first  to  the  second  period  of  the  disease  is  often 
so  slow  and  gradual  as  to  be  almost  imperceptible.  In 
some  cases,  however,  it  is  noticed  suddenly,  when  an  un- 
usual effort  is  made.  The  patient  then  finds  that  he  cannot 
do  what  he  wants  to  do,  and  begins  to  observe  himself.  In 
one  of  my  patients  (Case  21,  p.  105)  the  ataxy  was  first 
perceived  at  a  game  of  cricket,  when  he  found  that  he  could 
not  run  so  well  as  before.  Sometimes  it  comes  upon  people 
as  a  complete  surprise,  but  they  remember  afterwards  that 
somewhat  similar  occurrences  have  happened  before, 
although  at  the  time  they  did  not  realise  it.  Indeed, 
the  muscular  disorder  may  be  at  first   so  trifling  that  the 

Q 


226  SCLEROSIS  OF  THE  SPINAL  CORD. 

patient  succeeds  by  slight  unconscious  efforts  in  obviating 
any  actual  inconvenience. 

At  this  initial  period  of  the  second  stage  of  tabes,  a 
shilled  objective  exploration  of  the  patienfs  condition  is  of 
paramount  importance.  The  subjective  symptoms  of  which 
he  most  complains  are  often  misleading,  and  comparatively 
insignificant ;  while  the  principal  objective  siga  is  often  so 
concealed  that  only  the  specially  trained  observer  is  able 
to  recognise  and  appreciate  it.  At  this  time  a  patient  may 
still  be  able  to  walk  four  or  five  miles  at  a  time  without 
much  fatigue,  and  often  scouts  the  idea  that  there  is  any- 
thing wrong  with  his  walking  powers.  It  is,  therefore, 
necessary  to  make  him  go  through  a  certain  number  of 
tests,  some  or  all  of  which,  when  ataxy  is  present,  will  in- 
fallibly reveal  it.  The  more  important  of  these  tests  are 
the  following  : — 

a.  Getting  up. — A  healthy  person  has  no  difiiculty  in 
getting  up  from  a  low  chair  or  a  couch,  and  in  setting  off 
to  walk  immediately  afterwards.  In  the  tabid,  however, 
at  this  stage  a  certain  amount  of  hesitation  and  awkward- 
ness is  noticed,  when  he  is  requested  to  get  up  suddenly 
and  walk.  He  is  seen  to  collect  himself  for  an  instant, 
then  gets  up,  and  waits  a  little  while  in  order  to  balance 
himself  properly,  after  which  he  sets  off  and  then  appears 
to  have  little  or  no  difficulty  in  walking.  The  first  steps, 
however,  are  often  more  awkward  than  the  subsequent 
performance. 

At  this  period  both  legs  may  be  equally  affected ;  but 
occasionally  the  difficulty  appears  to  be  in  one  leg  only,  or 
at  least  in  one  leg  more  than  in  the  other. 

b.  Standing  is  likewise  felt  to  be  difficult.  The  patient 
dislikes  it,  and  wants  either  to  sit  down  directly,  or  to  take 
hold  of  something  to  support  himself.  He  sometimes  feels 
giddy  in  standing,  and  instinctively  prefers  standing  with 
his  feet  wide  apart,  so  as  to  enlarge  the  centre  of  gravity 
as  much  as  possible.     This  symptom  becomes  much  more 


SYMPTOMS  OF  TABES  SPINALIS.  227 

noticeable  when  the  patient  is  requested  to  stand  on  one 
leg.  Most  healthy  persons  are  able  to  do  this  quite  well, 
at  least  for  a  minute,  while  the  tabid  then  staggers  about 
like  a  drunken  man.  He  also  has  a  difficulty  in  raising 
himself  on  his  toes  while  standing. 

c.  A  further  sign  at  this  stage  is,  that  the  patient  is 
unable,  when  walking,  to  stand  still  immediately  when  re- 
quested to  do  so.  Healthy  persons  have  in  general  no 
difficulty  whatever  in  doing  this,  although  perhaps  not 
quite  as  promptly  as  soldiers  on  parade,  who  are  more 
efficiently  trained  for  it.  The  tabid,  however,  shows  an 
amount  of  embarrassment  at  such  a  juncture  which  is 
highly  characteristic.  If  he  attempts  to  stand  still  at  once, 
he  has  to  balance  himself  either  by  a  forward  or  a  back- 
ward movement,  and  sometimes  manoeuvres  with  his  arms 
at  the  same  time. 

d.  Another  useful  test  at  this  period  is  to  request 
the  patient  to  turn  quickly  round.  This  act,  although 
apparently  simple,  requires  the  harmonious  action  of 
numerous  groups  of  muscles,  and  is  generally  wretchedly 
performed  even  at  the  commencement  of  the  second  stage 
of  tabes. 

e.  A  further  excellent  test,  which  I  have  not  seen 
mentioned  in  any  previous  treatise  on  this  disease,  is  to 
make  the  "patient  walk  backwards.  This  faculty,  which  is 
chiefly  practised  and  valued  by  courtiers,  is  nevertheless 
possessed  by  all  ordinary  mortals  as  long  as  they  are  in 
good  health.  For  the  tabid  it  is  mostly  very  difficult  to 
walk  backwards  at  a  time  when  he  may  have  very  little  or 
no  trouble  in  walking  forwards.  His  heels  seem  to  catch 
the  ground  ;  he  dare  not  move  for  fear  of  falling  ;  and  if  he 
succeed  in  walking  backwards,  it  is  in  a  peculiarly  halting 
and  odd  fashion,  which  at  once  attracts  attention.  This 
symptom  I  have  occasionally  found  before  any  of  the  other 
tests  were  available,  and  it  is  then,  of  course,  of  more  par- 
ticular importance. 

Q2 


228  SCLEROSIS  OP  THE  SPINAL  CORD. 

I   noticed  this  symptom  for  the  first  time  in  the  case 
of  a  gentleman  aged  42  (Case  67),  who  consulted  me  in 
February,  1882,  and  who  was,  in  consequence  of  certain 
official   duties,    obliged  to  walk  backwards  a  good   deal. 
For  years  this  had  been  the  easiest  thing  in  the  world  for 
him ;  but  during  the  last  six  months  he  had  been  mortified 
to  find  that  he  experienced  considerable   difficulty  in  ac- 
complishing this  feat.      He  told  me  that  his  health  was 
otherwise  excellent,  with  the  exception  of  "rheumatic  pains" 
in  the  limbs,  to  which  he  had  been  subject  off  and  on 
during    the   last    three  years.      I  examined  him   for    the 
patellar  tendon  reflex,  and  found  it  absent  in  both  sides. 
In  the  further  course  of  the  interview  I  elicited  that  the 
patient  had  had  syphilis  ten  years   ago  ;    that  he  had  a 
temporary  attack  of  double  vision  about  three  years  ago ; 
that  there  was  occasionally  incontinence  of  urine  in  the 
morning  and  habitually  a  feeling  of  numbness  in  the  soles 
of  the  feet.     The  patient  was  still  able  to  walk  exceed- 
ingly well  in  the  daytime,  and  on  a  level  road,  but  had 
found  difficulty  in  walking  in  the  dark.      He  went  satis- 
factorily through  the  other  tests  which  I  am  in  the  habit  of 
using  at  this  stage  of  the  malady,  showing  that  he  was  only 
just  in  the  commencement  of  the  second  stage  of  tabes. 
The  walking  backward  was  indeed  the  most  troublesome 
thing  he  had  to   contend  with  ;  and  the  contrast  between 
the  clumsy  and  awkward  way  in  which  he  did  this,  and  the 
apparent  ease  with  which  he  walked  forward,  was  indeed 
striking.     When  attempting   to  walk  backwards,  his  heels 
seemed   to    become   entangled   in    the    carpet ;    he    was 
evidently  totally  unable  to  raise  his  feet  properly  from  the 
ground,  and  on  one  occasion  would   certainly   have  fallen 
unless  I  had  supported  him.    All  the  muscles  of  the  thighs 
and  legs  seemed  to  become  rigid  the  instant  he  attempted 
-to  walk  backwards,  while  in  walking  forward  he  appeared 
to  have  no  difficulty  whatever  in  bending  his  knees  to  the 
proper  degree. 


SYMPTOMS  OP  TABES  SPINALIS.  229 

Since  then  I  have  made  it  a  point  to  inquire  about  this 
symptom  in  patients  suffering  from  tabes,  and  have  found 
it  present  in  the  majority  of  cases.  In  an  artist,  who  is 
now  under  my  care,  this  difficulty  is  particularly  annoy- 
ing, because  it  prevents  him  from  taking  a  perspective  of 
his  pictures  by  walking  backwards  from  his  easel.  In 
this  case  there  are  no  symptoms  of  tabes  above  the 
waist,  so  that  the  patient  is  able  to  paint  as  well  as  ever. 

In  difficult  or  doubtful  cases  therefore,  more  especially 
in  those  at  the  very  threshold  of  the  second  or  ataxic 
stage  of  tabes,  the  symptom  which  I  have  mentioned 
may  put  us  on  the  right  track,  and  lead  us  to  examine 
the  patient  who  shows  it  for  other  symptoms  of  the 
malady.  As  tabes  is  still  frequently  confounded  with  gout, 
rheumatism,  neuralgia,  dyspepsia,  idiopathic  amaurosis,  and 
other  conditions,  any  addition  to  our  means  of  diagnosis 
for  that  time  where  the  malady  is  not  yet  fully  developed 
must  be  welcome. 

/.  The  most  striking  test,  however,  at  this  period  is 
"  Romberg's  symptom."  Romberg  ^  noticed,  as  far  back  as 
1840,  that  the  influence  of  light  is  a  very  important 
factor  in  such  cases.  He  says  that,  even  in  the  beginning, 
the  patient  must  see  his  movements  if  they  are  to  be  at  all 
certain.  When  at  our  request  he  stands  up,  and  then  shuts 
his  eyes,  he  at  once  begins  to  stagger  ;  and  when  he  is  in 
the  dark,  standing  and  walking  become  more  awkward. 
A  patient,  who  could  see  quite  well,  complained  of  being 
unable  to  work  and  dress  himself  in  the  dark,  in  the  morn- 
ing, without  falling.  Another  man,  who  had  to  go  to 
business  at  6  a.m.  in  the  winter,  stated  that  he  was  obliged 
to  have  a  servant  to  support  him,  which  was  not  required 
in  the  daytime.  At  a  later  stage  the  patient  may  not  even 
be  able  to  sit  on  a  chair  when  closing  his  eyes,  but  is  apt 
to  glide  gradually  down  from  it ;  and   on   coming  from  a 

'  "  Lehrbuch  der  Nervenkrankheiten  des  Menschen,"  vol.  iii.,  p.  184. 
Berlin,  1840. 


230  SCLEROSIS  OP  THE  SPINAL  COED. 

well-lighted  room    into    a    dark    one,    lie    loses    himself 
altogether. 

Romberg's  symptom  is  chiefly  marked  when  the  patient  is 
requested  to  stand  with  his  feet  closely  approiached  to  one 
another,  as  then  the  point  of  gravity  is  more  easily  dis- 
placed. Even  at  an  early  period  the  patient  begins  to 
manceuvre  with  both  arms,  in  order  to  prevent  himself  from 
falling.  "  He  uses  his  eyes  as  crutches  ; "  the  reason  for 
this  being  that  the  brain  intervenes  through  the  inter- 
mediate agency  of  the  sense  of  sight,  in  order  to  preserve 
the  balance  of  the  body  ;  and  he  stammers  with  his  feet. 

Some  patients,  when  walking,  look  constantly  at  near 
objects,  so  as  to  be  sure  to  find  support  on  the  shortest 
notice,  while  others  are  always  looking  at  their  legs  and 
feet,  and  endeavour  thereby  to  regulate  their  movements 
as  much  as  possible.  The  manoeuvring  increases  as  the 
disease  advances  ;  but  it  may,  in  the  beginning  of  the 
second  stage,  only  be  perceptible  to  the  eye  of  the  prac- 
tised observer. 

g.  Finally,  there  is  a  peculiar  symptom,  which  is  not 
nearly  so  constant  as  those  which  have  just  been  mentioned, 
but  which  nevertheless  is  of  some  importance.  This  is  a 
disinclination  on  the  part  of  the  patient  to  go  downstairSj 
while  there  may  be  no  difficulty  at  all  in  going  upstairs. 
To  look  down,  more  especially  a  long  flight  of  stairs, 
appears  to  unnerve  the  tabid,  who  is  anxious  to  secure  the 
support  of  the  baluster,  and  goes  down  very  slow)ly,  while 
looking  all  the  time  at  his  feet.  The  awkwardness  of  the 
performance  is  particularly  noticeable  when  the  observer 
stands  at  the  bottom  of  the  staircase.  In  a  patient  who 
was  sent  to  me  in  January,  1880,  by  Mr.  Hodgson,  of 
Brighton,  the  first  sign  of  ataxy  was  the  dread  which  he 
experienced  in  going  down  ladders  in  the  pursuit  of  his 
business  as  an  architect,  while  he  did  not  mind  going  up 
ladders  at  all. 

B.  The  Ataxic  Gait. — While,  therefore,  in  the  earlier  stages 


SYMPTOMS  OF  TABES  SPINALIS.  231 

ataxy  has  to  be  found  out,  and  discovered  by  special  modefc 
of  investigation,  the  phenomena  which  are  observed  in  the 
further  progress  of  the  disease  are  so  striking  that  no  diffi- 
culty can  be  experienced  in  recognising  them  at  first  sight 
as  part  and  parcel  of  the  malady  to  which  they  actually 

belong. 

After  a  time  the  difficulty  in  walking  becomes  so  con- 
siderable that  the  patient  is  seriously  alarmed  by  it.     He 
finds  it  very  troublesome  indeed  to  get  up  from  a  chair, 
and  has  generally  to  make  several  separate  efforts  to  do  so  ; 
he  then  stands  with  his  body  bent  forward,  his  legs  rigid 
and  far  apart,  and  with  his  arms   stretched  out,  in  order 
to  increase  the  base  of  his  support,  and  enlarge  the  centre 
of  gravity.     If  we  now  examine  his  muscles,  all  of  them 
feel  completely  rigid.     The  patient  takes  instinctively  the 
greatest    trouble   to   keep   the    ankle   immovable,    and   to 
stretch  the  leg  well  on  the  thigh  ;  and  he  walks  chiefly  by 
the    aid    of  the  pelvic  and  femoral  muscles.     The  knees 
are,  therefore,  not  properly  bent,  so  as  to  clear  the  ground 
well   on    going   forward.       While   the   paralytic    is    seen 
to  have  a  difficulty  to   detach  his  feet  from  the    ground, 
and  often  scrapes  the  boards  or  the  carpet  with  his  feet  or 
boots,  the  ataxic,  on  the  contrary,  throws  the  feet  too  much 
forward  and  outwards,  with  a  peculiarly  rapid  jerk  ;  the  heel 
is  therefore  carried  too  far  ahead  to  come  down  properly, 
is  pulled  back,  and  eventually  comes  down  with  a  heavy 
thud  or  thump,  stamping  the  ground.     Sometimes  the  foot 
comes  down  flat,  instead  of  on  the  heel,  and  the  shock  of 
this  may  be  so  great  that  it   adds  to  the  trouble,  and  the 
patient,  in  order  to  avoid  it  imparts  to  the  leg  a  swinging 
motion.     At  other  times   he   finds  it  impossible  to  walk 
slowly,  but   walks  very   fast,   and    actually   runs  without 
being  able  to  stop  or  to  change  the  direction  in  which  he 
walks.      Turning  round   is   then   extremely  troublesome. 
All  the  time  the  patient  is  on  his  legs,  he  fixes  an  intense 
and  anxious  gaze  on  his  feet,  endeavouring  to  control  their 


232  SCLEROSIS  OF  THE  SPINAL  CORD. 

movements  with  his  eyes  to  the  utmost  of  his  power,  and 
so  to  prevent  himself  from  falling,  which  is  his  constant 
dread.  If  at  this  stage  he  walks  in  the  streets,  and  runs 
against  people,  or,  what  is  more  frequent,  if  people  run 
against  him,  he  is  called  "  a  drunken  brute,"  and  occa- 
sionally taken  to  the  police  station.  He  is  presently 
obliged  to  walk  with  a  stick,  or  to  support  himself  on  either 
side  by  a  servant  or  a  nurse. 

C.  The  stage  of  Muscular  Madness. — As  the  disease  ad- 
vances, the  ataxic  gait,  as  just  described,  loses  its  character- 
istic features.  The  patient  is  now  no  longer  able  to  fix  the 
ankle  and  knee  joints,  which  used  to  be  some  check  to  the 
muscular  incoordination  of  a  former  period.  When  he 
now  attempts  to  walk,  he  searches  continually  with  his  feet 
for  a  support  which  he  cannot  find,  his  legs  are  utterly  be- 
yond his  control,  the  movements  altogether  disorderly,  and 
so  many  muscles  act  at  the  wrong  time,  and  in  the  wrong 
combination,  that  no  useful  result  can  be  obtained.  There 
are  sometimes  real  cramps,  and  such  a  degree  of  muscular 
madness  that  the  feet  fly  about  anywhere,  and  are  knocked 
against  the  sticks  or  the  legs  of  the  persons  supporting  the 
patient.  There  is  such  kicking  and  sprawling  that  the  pa- 
tient gives  the  impression  of  a  drunken  man,  or  of  one  who 
is  on  skates  for  the  first  time,  or  who  attempts  to  walk  on 
board  ship  during  a  heavy  gale.  The  efforts  which  he  has 
to  make  to  prevent  himself  from  falling,  by  manoeuvring  at 
the  same  time  with  different  groups  of  muscles  over  which 
he  has  lost  all  control,  soon  lead  to  exhaustion  by  the  ex- 
penditure of  so  large  an  amount  of  muscular  force ;  and  the 
patient  is,  therefore,  only  too  glad  to  go  back  to  his  couch, 
where  he  drops  down  with  a  sigh  of  relief,  and  in  a  state  of 
prostration. 

In  some  cases  it  is  seen  that  the  patient  endeavours  to 
check  the  muscular  disorder  by  keeping  the  feet  as  close 
as  possible  to  the  ground,  and  therefore  drags  one  leg  after 
the  other,  so  that  the  walk  resembles  at  first  sight  that  of 


SYMPTOMS  OF  TABES  SPINALIS. 


233 


paraplegia.  It  is  however  obvious,  even  at  tiiis  stage,  that 
there  is  plenty  of  muscular  force  left,  as  the  patient  may 
still  stand  erect  when  supported  against  a  wall  or  by  a 
heavy  piece  of  furniture.  Duchenne,  in  order  to  demon- 
strate this,  used  to  raise  himself  on  the  shoulders  of  such 
patients  when  they  were  securely  placed,  and  especially 
had  their  feet  far  apart,  without  their  giving  way  ;  and  a 
dynamometer  for  measuring  the  force  in  the  legs,  which 
Messrs.  Weiss  and  Son  have  constructed  for  me,  has  often 
at  this  stage  shown  me  that  the  muscular  power  of  the  legs 
remained  undiminished.  The  patient  may  also  resist 
attempted  flexion  of  the  knee  by  calling  into  play  the  action 
of  his  extensors,  or  attempted  extension  by  using  the 
flexors  ;  and  the  simple  stretching  of  the  flexed  leg,  which 
he  is  still  able  to  do  at  a  very  advanced  period  of  the 
malady,  is  often  performed  with  considerable  force. 

Crutches  are  sometimes  of  use  to  the  patient.  An  army 
surgeon  who  was  under  my  care  in  July,  1878,  for  a  severe 
form  of  tabes,  which,  however,  showed  no  symptoms  above 
the  waist,  was  absolutely  helpless  without  crutches,  but 
with  their  aid  managed  to  walk  about  the  streets  of  London, 
although  in  a  sprawling  fashion.  In  some  cases,  however, 
where  the  jerky  and  spasmodic  element  is  very  marked, 
crutches  or  even  the  support  of  other  persons'  arms  are  of 
very  little  use,  as  there  is  so  much  sprawling  about  with 
the  legs  that  the  crutches  are  thrown  about  in  a  useless* 
fashion,  and  it  may  happen  that  an  attendant,  unless  very 
steady  on  his  own  legs,  is  actually  thrown  over  by  the 
patient.  Again,  when  there  is  ataxy  in  the  upper  ex- 
tremities, the  walking  gets  proportionately  worse,  since 
the  use  of  sticks,  crutches,  attendants,  and  even  taking 
hold  of  pieces  of  furniture,  such  as  chairs,  tables,  etc., 
becomes  impossible,  and  the  patient  is  to  all  intents  and 
purposes  as  completely  helpless  as  one  who  is  actually 
paralysed. 

It  is  important  at  any  time  during  the  second  stage  of 


234  SCLEROSIS  OP  THE  SPINAL  CORD. 

tabes  to  examine  the  patient  in  the  horizontal  position,  when 
he  is  quietly  lying  on  a  bed  or  couch,  as  it  is  chiefly  then 
that  the  immense  difference  which  exists  between  ataxy 
and  paralysis  arrests  attention.      When  a  patient   suffering 
from  paraplegia,  who  is  lying  in  bed  or  on  a  couch,  is  asked 
to  move  his  lower  limbs,  the  first  thing  he  does  is  tO  help 
himself  with  his  hands,  and  to  make  a  general  movement 
of  the  whole  body,  in  order  to  bring  the  legs  forward,  or  to 
change  their  position.     The  legs  themselves  remain  almost 
or  entirely  inert,  according  to  the  degree  of  paralysis  which 
may  be  present,  while  efforts  are  made  by  all  the  other 
parts  of  the  body.     In  ataxy,  on  the  contrary,  even  at  an 
advanced  stage,  the  patient  has  no  difficulty  in  moving  his 
legs  in  bed,  although  they  may  be  quite  useless  for  walking. 
There  is  only  an  impossibility  of  orderly  and  useful  move- 
ments of  the  legs.  The  patient  cannot  raise  the  extended  leg 
quietly  and  gradually  into  the  air,  as  may  be  done  without 
any  difficulty  by  a  healthy  person  ;  on  the  contrary,  when 
he  attempts  this,  disorderly  movements  follow,  he  stretches 
the  whole  extremity,  and  throws  it  out  of  bed  in  a  violent 
manner,  either  by  a  single  bound  or  by  several  irregular  jerks. 
The  movement  of  abduction  being  particularly  sudden  and 
forcible,  those  who  are  near  the  bed  may  receive  a  kick 
before  they  have  time  to  reflect.    If  you  ask  the  patient  why 
he  stretches  the  whole  limb  whenever  he  is  requested  to 
make  any  movement,  he  replies  that  it  is  the  only  way  to 
make  any  use  of  his  muscles.      He  has  also  a  difficulty  in 
holding  his  leg  up  for  more  than  a  second  or  two,  nor  can 
he  bring  it  down  on  the  couch   gradually.      Again,  if  the 
hand  of  the  observer  be  placed  at  some  elevation   above 
the  bed  or  couch,   and  the  patient  be  requested  to  place 
one  of  his  feet  in  it,  he    can    only  succeed   in  doing   so 
by  chance  ;  in  general  there  are  ineffectual  attempts  made, 
in  which  the  foot  is  jerked  about  in  any  direction  but  the 
one  that  was  intended.      If  the  patient  be  told  to  touch  his 
own  knee  with  the  opposite  heel,  he  may  possibly  be  able 


SYMPTOMS  OF  TABES  SPINALIS.  235 

to  do  it  when  looking  on,  but  fails  in  accomplishing  it  with 
his  eyes  closed,  at  least  for  the  first  time,  while  after  a 
few  ineffectual  efforts  he  sometimes  succeeds  in  doing  it. 
The  influence  of  the  eyes  is,  however,  chiefly  important 
when  sensibility  is  at  the  same  time  much  diminished  ;  and 
the  power  which  is  put  forward  for  effecting  a  certain  pur- 
pose is  always  in  excess  of  that  which  would  be  used  by  a 
healthy  person. 

'  In  the  majority  of  cases  the  evolution  of  the  ataxy  is 
so  slow  as  to  be  almost  imperceptible.  Occasionally,  how- 
ever, it  comes  on  in  a  more  acute  form. 

Case  68. — In  August,  1881,  Mr.  Leftwich,  of  New 
Cross,  asked  me  to  see  a  male  patient,  aged  thirty-six, 
who  was  employed  as  compositor  at  the  Bank  of  England, 
and  had  been  greatly  overworked  in  the  month  of  March. 
At  the  end  of  that  month  he  was  suddenly  taken  with 
lightning  pains  in  the  back  and  the  left  hip,  inability  to 
walk,  and  incontinence  of  urine.  The  patient  strenuously 
denied  any  previous  syphilitic  infection.  Romberg's  and 
Westphal's  symptoms,  together  with  the  other  signs  of 
tabes  affecting  the  lower  dorsal  and  upper  lumbar  portion 
of  the  cord  were  present  when  I  examined  him. 

Cases  of  acute  ataxy,  like  the  preceding  one,  are  most 
probably  more  of  a  functional  than  of  a  structural  character. 
The  patients  generally  improve  a  good  deal  under  treatment 
in  a  short  time,  and  sometimes  get  quite  well. 

Ataxy  in  the  upper  extremities  is  seen  at  an  early  stage 
in  those  cases  where  the  disease  commences  in  the  cervical 
enlargement,  instead  of,  as  usual,  in  the  dorso-lumbar  por- 
tion of  the  cord.  In  most  cases  it  begins  in  the  upper 
extremities  a  considerable  time  after  the  lower  limbs 
have  become  useless,  and  is  then  a  sign  that  the  morbid 
change  is  creeping  upwards  in  the  spinal  cord.  Here  also, 
when  ataxy  is  present,  the  patient  may  still  have  a  power- 
ful biceps,  and  squeeze  the  dynamometer  almost  to  its 
utmost  limits,  showing  that  coarse   muscular  force  is  still 


236  SCLEROSIS  OF  THE  SPINAL  CORD. 

present.  In  general  we  find  that  the  ataxy  is  more  hable 
to  invade  the  muscles  of  the  wrist  and  the  fingers  than 
those  of  the  shoulders  and  the  arm.  The  patient  has  a 
difiiculty  in  buttoning  his  sleeves,  in  striking  a  match,  in 
picking  up  small  objects  like  a  pin,  in  carrying  a  cup  of  tea 
to  his  mouth  without  spilling  some,  or  in  carving  a  joint. 
If  we  give  him  a  pencil-case,  or  a  knife,  or  a  similar  object, 
to  hold  in  his  fingers,  he  is  apt  to  drop  it.  With  his  eyes 
closed,  or  in  the  dark,  the  awkwardness  of  his  movements 
is  still  more  marked.  In  France,  a  favourite  test  is  to 
make  the  patient  cross  himself,  and  to  notice  the  difficulty 
he  experiences  in  making  the  sign  of  the  cross  with  his 
finger.  In  this  country  a  similar  test  is  inapplicable  in  the 
majority  of  cases,  and  is  replaced  by  the  more  secular  one  of 
requesting  the  patient  to  touch  his  nose  with  his  first  finger. 
It  affords,  occasionally,  a  strange  sight  to  watch  the  pere- 
grinations of  the  finger  in  search  of  the  prominent  feature. 
Patients  who  take  snuff  have  a  difficulty  in  indulging  in 
their  favourite  pastime,  as  the  snuff  is  often  thrown  to  a 
considerable  distance  without  reaching  the  nostrils,  and 
occasionally  loses  its  way  into  the  mouth,  where  it  is  less 
acceptable.  Carpenters,  when  still  at  work,  let  the  hammer 
come  down  on  their  hands  rather  than  on  the  nails  they 
wish  to  fix  ;  and  skilled  artisans,  like  watchmakers,  jewel- 
lers, &c.,  are  no  longer  able  to  carry  out  those  minute  and 
skilful  manipulations  which  are  required  in  their  trades. 
The  patient,  after  a  time,  becomes  so  clumsy  and  awkward 
with  his  fingers,  and  goes  about  his  work  in  such  a  round- 
about manner,  that  he  ceases  to  be  useful,  and  is  discharged 
by  his  employers. 

Musicians  lose  their  facility  in  the  execution  of  compli- 
cated passages  which  were  formerly  like  child's  play  to 
them,  and  could  be  carried  out  without  looking  either  at 
their  fingers  or  their  instrument.  All  manipulations  with 
the  fingers  are  apt  to  become  more  difficult  when  the 
patient  closes  his  eyes.     If  one  hand  is  put  into  a  certain 


SYMPTOMS  OF  TABES  SPINALIS.  237 

position,  and  the  patient  is  requested  to  put  the  other  hand 
into  an  analogous  position,  he  is  unable  to  do  this  without 
looking.  When  the  ataxj  reaches  the  stage  of  muscular 
madness,  similar  irregular  movements  take  place  in  the 
upper,  as  we  have  seen  them  to  occur  in  the  lower  ex- 
tremities. Drummondi  mentions  the  case  of  a  patient 
who  was  searching  for  his  left  hand,  having  lost  it  under 
the  bed-clothes,  when  suddenly  the  missing  member  flew 
up,  and  struck  him  a  severe  blow  in  the  face.  This  arm 
often  moved  about  by  itself,  being  almost  entirely  beyond 
volitional  control,  and  was  even  jerked  about  during  sleep. 
These  irregular  movements  appear  to  set  in  chiefly  when 
parts  of  the  skin,  which  are  in  a  state  of  hyperaesthesia, 
are  irritated. 

The  muscles  of  the  body  rarely  show  any  ataxy.  Respi- 
ration may,  however,  be  irregular,  and  there  may  be  sway- 
ing of  the  body  and  the  head  from  one  side  to  another, 
similar  to  nystagmus.  The  latter  is  habitually  met  with  in 
Friedreich's  disease,  but  not  in  tabes  proper.  When  there 
is  much  ataxy  in  the  muscles  of  the  body,  the  patient  is 
unable  to  sit  on  a  chair  or  couch,  and  may  even  roll  out 
of  bed  without  being  able  to  help  himself.  Difficulty  in 
speaking,  partaking  of  the  nature  of  ataxy,  is  sometimes 
encountered  ;  and  the  ocular  and  facial  muscles  occasion- 
ally show  similar  symptoms. 

Ataxy  of  the  ocular  muscles  was  very  conspicuous  in  the 
case  of  a  patient,  aged  41,  single,  who  consulted  me  in 
June,  1884  (Case  69).  He  had  had  a  chancre  and  bubo, 
followed  by  "  plenty  of  secondaries  "  in  the  throat,  ulcera- 
tions in  the  tongue,  which  had  to  be  cauterised,  and  sores 
in  the  thigh.  He  underwent  a  long  and  persevering  treat- 
ment, and  seemed  quite  well,  when  he  caught  a  severe  cold 
in  February,  1883,  after  which  lightning-pains  and  ataxy 
of  gait  made  their  appearance.  The  pains  felt  partly  like 
blows  with  a  hammer,  which  were  principally  given  on  the 
»  "  British  Medical  Journal,"  Sept.  22,  1883. 


238  SCLEROSIS  OF  THE  SPINAL  CORD. 

knees  ;  and  sometimes  as  if  thousands  of  fish-hooks  had 
got  hold  of  the  calves  of  his  legs,  and  were  dragging  them 
up.  Romberg's,  Westphal's,  and  Argyll-Robertson's  symp- 
toms are  present.  His  legs  are  numb,  and  feel  as  if  he  had 
been  asleep  and  lying  in  water  for  a  long  time.  There  are 
symptoms  on  the  part  of  the  bladder,  bowels,  and  sexual 
organs  which  it  is  not  necessary  to  detail.  He  always  feels 
exhausted,  and  always  in  pain.  There  is  numbness  in  both 
hands,  more  especially  the  left ;  and  his  back  feels  as  if  he 
had  been  struck  by  a  thickly  covered  mallet,  or  as  if  he 
were  suddenly  being  dragged  down  by  the  backbone.  The 
most  interesting  symptom  about  him,  however,  was  true 
ataxy  of  the  ocular  muscles.  There  was  no  paralysis  in 
any  of  them,  nor  nystagmus  ;  but  the  patient  had  the 
greatest  difficulty  in  combining  them  to  synergic  action. 
The  consequence  was  that  he  saw  easily  double,  and  that 
more  especially  a  sudden  purposive  movement  of  the  eyes 
was  distressing  to  him.  The  most  difficult  thing  for  him 
was  to  look  up  to  the  ceiling,  although  the  muscles  con- 
cerned in  this  movement  showed  no  trace  of  paresis  or 
paralysis.  He  felt,  however,  so  strained  and  giddy  when 
attempting  this  movement,  that  he  immediately  afterwards 
closed  his  eyes,  and  threw  himself  back  exhausted  into  his 
chair.  Everything  was  then  double  or  a  confused  mass, 
and  he  could  only  see  well  when  closing  one  eye.  There 
was  no  colour-blindness,  and  no  trace  of  optic  atrophy. 

Although  in  the  majority  of  cases  the  symptoms  are 
symmetrical,  yet,  in  some  cases  ataxy  as  well  as  other 
symptoms,  are  confined  to  one  side  of  the  body  in  the 
second  stage  of  tabes  ;  and  this  condition  has  been  called 
hemi-ataxy.  Thus  some  patients  have  amblyopia  on  one 
eye,  and  say  that  they  have  a  good  leg  and  a  bad  leg.  Pain 
and  anaesthesia  are  sometimes  confined  to  one  side.  In  a 
case  which  was  sent  to  me  by  Dr.  Pearce,  of  Leicester,  in 
July,  1880,  the  patient  had  had  iritis  in  the  left  eye,  had 
numbness  in  the  left  ulnar  nerve,  much  more  numbness  in 


SYMPTOMS  OF  TABES  SPINALIS.  239 

the  left  than  in  the  right  leg,  tightness  in  the  left  side  of 
the  head,  neck,  and  shoulder,  and  pain  generally  confined 
to  the  left  side.  He  would,  for  instance,  get  a  shoot  of 
pain  in  the  left  wrist,  which  would,  when  at  dinner,  make 
him  suddenly  drop  his  fork  ;  hut  this  did  not  occur  in  the 
right  wrist.  This  peculiarity,  however,  generally  becomes 
less  marked  as  time  goes  on,  when  the  other  side  becomes 
similarly  affected.  In  a  few  cases,  however,  it  appears  to 
remain  so  throughout  the  whole  course  of  the  disease. 

Several  theories  have  up  to  the  present  time  been 
brought  forward  for  explaining  physiologically  the  pheno- 
mena of  ataxy  which  have  just  been  described.  Some 
observers,  and  more  particularly  Friedreich  ^  and  Erb  ^ 
state  that  ataxy  is  a  true  motor  symptom,  and  not  in  any 
way  connected  with,  or  dependent  upon,  the  anaesthesia 
which  is  generally  present  at  the  same  time.  They  base 
their  views  on  the  fact  that  in  many  cases  the  degree  of 
ataxy  is  not  at  all  proportionate  to  the  degree  of  anaesthesia 
which  may  be  found,  inasmuch  as  the  one  may  be  slight, 
and  the  other  severe,  and  vice  versa.  A  further  apparent 
support  has  lately  been  given  to  this  view  by  the  discovery 
that  neuritis  of  the  peripheral  nerves  has,  at  least  in  some 
cases,  to  be  looked  upon  as  the  cause  of  any  high  degree 
of  anaesthesia  which  may  be  present  (p.  30).  Moreover, 
complete  anaesthesia  of  one  side  of  the  body  has  been  seen 
in  hysterical  women,  and  after  certain  cerebral  lesions, 
without  being  apparently  accompanied  with  ataxy. 
Finally  there  is  a  wonderful  case,  known  as  Spath- 
Schiippel's  case  ^  which  will  no  doubt  do  duty  for  many 
years  to  come,  like  that  of  the  Count  de  Lordat  in 
another  chapter  of  spinal  pathology,  and  which  is  now  by 
several  pathologists  believed  to  have  settled  this  question 

'  Virchow's  "  Archiv,"  vol.  Ixviii.,  1876,  and  vol.  Ixx.,  1877. 
2  "  Krankheiten  des  Riickenmarka,"  p,  85.     Leipzig,  1876. 
'"Beitrjige  zur  Lehre  von  der  Tabes  Dorsualis,"  Tubingen,  1864, 
and  "  Archiv  fiir  Heilkunde,"  vol.  xv.,  p.  45,  1874. 


2d0  SCLEROSIS  OF  THE  SPINAL  CORD. 

for  ever.  The  patient  who  was  the  subject  of  this  remark- 
able case  suffered  from  complete  cutaneous,  muscular, 
and  articular  anaesthesia,  owing  to  spinal  disease,  while 
there  was  no  trace  of  ataxy  in  walking.  After  death 
hydromyelus  was  found,  and  wasting  of  the  posterior 
columns  in  the  lower  portion  of  the  cervical  cord,  while 
the  dorsal  portion  was  only  slightly  atrophied,  and  the 
lumbar  portion  normal.  The  lateral  columns,  the  grey  com- 
missure and  the  posterior  horns  were  likewise  much  affected, 
and  the  posterior  roots  of  the  third  to  the  eighth  cervical 
nerves  sclerosed,  while  the  anterior  columns,  horns,  and 
roots  were  normal.  Erb  has  argued  that  if  a  normal  con- 
dition of  sensibility  were  really  essential  for  co-ordination, 
there  ought  to  have  been  a  high  degree  of  ataxy  in  this 
case,  since  anaesthesia  was  complete  ;  there  was,  however, 
no  ataxy,  and  he  therefore  thinks  that  sensibility  is  not 
indispensable  for  co-ordination ;  it  may  be  necessary 
for  first  learning  to  co-ordinate  movements,  and  is  un- 
doubtedly of  importance  for  equilibration,  but  is  unneces- 
sary for  carrying  out  complex  movements  which  have 
already  been  learnt  by  training.  He  therefore  assumes  the 
existence  in  the  cord  of  special  co-ordinating  centrifugal 
fibres,  and  thinks  that  ataxy  is  only  observed  when  these 
centrifugal  fibres  are  diseased.  He  appears  to  suppose  that 
they  are  situated  either  in  the  central  grey  matter  or  in  the 
lateral  columns,  but  leaves  this  point  open  for  future  in- 
vestigations. 

On  the  other  hand.  Ley  den  ^  and  Pierret^  have  argued 
that  tabes  is  really  a  disease  of  the  sensory  tracts  only,  and 
that  all  symptoms  of  motor  disturbance  which  occur  in  it 
are  to  be  explained  by  the  influence  which  sensation  is 

^"TJeber  die  graue  Degeneration,"  etc.,  Berlin,  1863;  and  article 
"Tabes  Dorsalis,"  in  Enlenburg's  " Encyclopadie,"  p.  57.  Vienna, 
1883. 

2  "Transactions  of  the  International  Medical  Congress  of  London," 
1881.    Vol.  ii.,  p.  399. 


SYMPTOMS  OF  TABES  SPINALIS.  241 

known  to  have  on  motion,  or  by  the  intimate  relations  ex- 
isting between  the  motor  and  sensory  tracts.  Leyden  finds 
the  principal  bases  of  this  theory  to  be  the  following  : — 

1.  The  portions  of  the  cord  which  suffer  in  tabes  are 
notoriously  concerned  with  sensibility.  This  is  more  cer- 
tain of  the  posterior  roots  than  of  the  posterior  columns. 
Van  Deen  has  asserted  that  the  latter  are  sensitive,  but 
Schiff  has  proved  the  contrary.  Their  relation  to  the 
posterior  roots,  however,  is  undoubted  from  anatomical 
and  evolutional  considerations,  Burdach's  columns  being 
the  direct  continuation  of  the  posterior  roots,  while  Groll's 
columns  are  generally  considered  to  be  the  centripetal  con- 
tinuation of  these  fibres  towards  the  brain.  The  principal 
bulk  of  the  posterior  columns  is  therefore  composed  of 
afferent  fibres  ;  there  are  no  positive  reasons  for  assuming 
the  existence  in  them  of  other  fibres  of  unknown  function, 
while  the  occurrence  of  centrifugal  fibres  in  these  parts  is 
incompatible  with  the  structure  of  the  posterior  columns. 

2.  Sensibility  always  suffers  in  tabes  ;  lightning  pains, 
parsesthesia,  and  anassthesia  are  constant  symptoms. 

3.  A  normal  condition  of  sensibility  is  indispensable  for 
normal  co-ordination  of  movements  ;  and  where  sensibility 
is  affected,  co-ordination  suffers  likewise. 

4.  The  affection  of  sensibility  in  tabes  is,  if  not  abso- 
lutely, at  least  tolerably  proportionate  to  the  degree  of 
ataxy  which  may  be  present. 

5.  Certain  nearly  constant  signs  of  tabes,  such  as 
Romberg's  symptom,  can  only  be  explained  by  the  part 
which  sensibility  plays  in  co-ordination. 

Leyden  disposes  summarily  of  the  objections  which  have 
been  made  against  the  sensory  theory  of  tabes.  When  it  is 
stated  that  there  are  cases  of  tabes  with  ataxy  where  even 
the  most  careful  exploration  of  the  different  kinds  of  sensi- 
bility sliows  the  latter  to  be  unaffected,  he  replies  that 
either  the  examination  has  not  been  sufficiently  exact,  or 
the  cases  have  not  been  those  of  tabes.     There  arc  certain 

R 


242  SCLEROSIS  OF  THE  SPINAL  CORD. 

forms  of  acute  ataxy  and  of  Friedreich's  disease  which 
cannot  be  looked  upon  as  appertaining  to  tabes  proper. 
Again,  it  has  been  stated  that  an  affection  of  motility  which 
may  be  experimentally  produced  by  interfering  with  sen- 
sory paths  does  not  resemble  typical  ataxy  ;  but  this 
Leyden  thinks  of  little  consequence,  the  principal  thing  being 
that  motility  suffers  when  sensibility  is  impaired.  Artifi- 
cially produced  conditions  are  in  any  case  so  different  from 
tabes  as  a  disease,  that  complete  analogy  cannot  be  ex- 
pected. Finally,  with  regard  to  certain  forms  of  anaesthesia 
which  exist  without  ataxy,  viz.,  those  which  occur  in 
hysterical  women  and  cerebral  hemi-an£esthesia,  he  con- 
siders that  hemi-angesthesia  proves  nothing,  and  anaesthesia 
in  hysterical  women  as  good  as  nothing ;  while  Spath- 
Schlippel's  case  appears  to  him  to  prove  even  less.  A 
single  case,  with  uncommon  clinical  features,  and  showing 
uncommon  post-mortem  changes,  is  as  little  conclusive  as 
a  single  experiment  which  cannot  be  repeated  with  the 
same  results. 

It  thus  appears  that  the  two  principal  representatives  of 
German  pathology  of  the  present  day  differ  toto  ccelo  in 
their  views  of  this  important  subject.  A  careful  critical 
consideration  of  all  the  different  points  in  dispute  seems 
therefore  necessary  in  order  to  enable  us  to  arrive  at  a  satis- 
factory conclusion  ;  and  I  will  begin  this  difficult  part  of 
my  subject  with  an  examination  of  the  data  which  are 
furnished  to  us  by  anatomy  and  physiology  concerning  the 
question  now  under  discussion. 

The  anatomical  and  evolutional  facts  which  have  been 
given  in  the  first  chapter  (pp.  8-10)  appear  very  clear  as  far 
as  they  go.  We  have  seen  that  the  posterior  columns  con- 
sist of  two  different  systems,  one  of  which,  viz.,  Burdach's 
columns,  have  to  be  looked  upon  as  short  conducting  paths, 
while  the  other,  viz.,  Goll's  columns,  are  long  conducting, 
paths.  Burdach's  columns  are  direct  continuations  of  the 
posterior   root-fibres  ;    they   connect    the  cord  with  peri- 


SYMPTOMS  OF  TABES  SPINALIS.  243 

pheral  parts,  and  thereby  with  external  influences.  They 
also  send  out  numerous  fibres,  which  proceed  in  various 
directions  into  the  central  grey  matter,  and  which  are 
evidently  intended  to  connect  the  different  segments  of  the 
grey  matter  with  each  other,  while  others  again  proceed 
upwards  into  the  medulla  oblongata,  where  they  terminate. 
Goll's  columns,  on  the  other  hand,  which  are  immediately 
contiguous  to  Burdach's  columns,  are  long  conducting 
paths,  which  proceed  from  the  central  grey  matter  of  the 
cord  up  to  the  medulla  oblongata,  and  appear  from  their 
anatomical  peculiarities  intended  to  connect  extra-medullary 
centres  in  the  brain  and  cerebellum  with  physiologically 
identical  fibre-systems  at  different  levels  of  the  cord.  It 
seems,  prima  facie,  reasonable  to  assume  that  the  various 
commissures  which  are  intended  to  establish  a  connection 
between  extra-  and  intra-medullary  centres,  put  all  of 
these  into  mutual  functional  relations,  and  form  a  path  for 
producing  a  physiological  consensus  between  them.  De- 
struction of  these  anatomical  commissures  by  disease  would 
therefore  naturally  be  expected  to  lead  to  a  cessation  of  at 
least  some  degree  of  functional  harmony. 

Experimental  physiology,  on  the  other  hand,  has  given 
hitherto  somewhat  ambiguous  results,  which  seem  at  first 
sight  in  contradiction  to  the  data  of  normal  and  morbid 
anatomy.  Schiff  has  shown  that  division  of  the  posterior 
columns  in  animals  causes  loss  of  the  sense  of  touch  in  all 
parts  behind  the  lesion,  but  not  loss  of  the  sensation  of 
pain,  or  analgesia.  On  the  other  hand,  Goltz,  who  has 
studied  the  question  of  the  localisation  of  the  faculty  of  co- 
ordination, has  come  to  the  conclusion  that  no  centres  for 
the  co-ordination  of  complex  movements  exist,  either  in 
the  posterior  columns,  or  in  fact  anywhere  throughout  the 
entire  extent  of  the  cord,  but  that  such  centres  are  to  be 
found  in  the  brain,  more  particularly  in  the  corpora  quadri- 
gemina,  the  optic  thalamus,  and  the  cerebellum.  As  there- 
fore the  posterior  columns  do  not  appear  to  be  the  centres 

R  2 


244  SCLEROSIS  OF  THE  SPINAL  CORD. 

of  co-ordination,  we  might  at  least  expect  them  to  contain 
the  paths  by  which  the  co-ordinating  impulses  travel  from 
the  brain  to  the  muscles.  But  even  this  supposition  is 
controverted  by  Woroschiloff's  experiments,  which  tend  to 
show  that,  at  least  in  the  rabbit,  these  paths  are  situated 
in  the  middle  third  of  the  lateral  columns  of  the  cord,  and 
do  not  touch  the  posterior  columns  at  all. 

The  physiology  of  the  posterior  roots  is  somewhat  better 
known  than  that  of  the  posterior  columns.  If  the  posterior 
roots  for  one  hind-leg  are  divided  in  a  frog,  the  movements 
of  that  leg  are  seen  to  be  out  of  harmony  with  the  other, 
whether  for  jumping,  swimming,  or  other  modes  of  loco- 
motion ;  it  appears  clumsy  and  inert  ;  and  when  such  an 
animal  is  held  between  the  fingers,  the  affected  leg  will 
not  make  the  movements  intended  for  the  purpose  of 
escaping,  as  is  done  by  the  unaffected  leg.  After  experi- 
mental division  of  the  whole  of  the  posterior  roots,  a  frog, 
when  put  into  water,  is  seen  to  be  unable  to  swim  ;  and, 
if  incited  to  do  so,  gives  himself  up  to  ataxic  movements 
without  attaining  its  purpose.  Locomotion  is  therefore 
seen  to  be  deeply  influenced  by  sensorial  impressions  im- 
parting to  the  animal  information  about  the  position  of 
different  parts  of  its  body  ;  and  when  this  information  is 
uncertain,  incorrect,  or  altogether  absent,  want  of  coordi- 
nation is  seen  to  follow. 

It  is  important  to  notice  that  impressions  which  are 
simply  and  solely  furnished  by  the  skin  are  not  indispen- 
sable for  locomotion.  Thus  Claude  Bernard  has  shown  that 
a  frog,  whose  skin  was  entirely  removed,  could  still  swim 
quite  well ;  while  destruction  of  the  posterior  roots  at  once 
put  a  stop  to  the  power  of  swimming.  This  fact  has  a  dis- 
tinct bearing  on  those  cases  where  ataxy  has  been  observed 
together  with  normal  sensibility  in  the  skin.  Our  notions 
of  the  position  of  our  limbs  are  evidently  not  only  deter- 
mined by  the  sensibility  of  the  skin,  but  also  of  the  more 
deeply    situated    structures,    such   as   muscles,  ligaments. 


SYMPTOMS  OF  TABES  SPINALIS.  245 

cartilages,  and  bones,  which  may  lose  their  sensibility  in- 
dependently of  that  of  the  skin.  It  is  true  that  in  many 
cases  of  hysterical  hemi-ansesthesia  the  movements  of  pre- 
hension, locomotion,  etc.,  are  reported  to  have  been  normal ; 
but  there  are  other  cases  in  which  unquestionably  ataxy 
of  movements  exists  under  such  circumstances.  In  a 
girl,  aged  eleven,  who  is  at  present  (June,  1884)  under  my 
care  at  the  hospital,  there  was,  on  admission,  hemi- 
anaesthesia  of  the  entire  left  side  of  the  body,  which  had 
apparently  come  on  through  hsemorrhage  into  the  most 
posterior  portion  of  the  internal  capsule  at  the  time  of 
birth.  The  affection  had  continued  unaltered  all  her  life 
until  she  came  under  my  care,  but  yielded  nevertheless  to 
a  single  application  of  electricity.  There  had  been  no  sign, 
of  paralysis  at  any  time,  and  the  girl  was,  on  examination, 
found  to  be  well  able  to  carry  out  every  simple  movement 
with  the  anaesthetic  limbs  which  I  asked  her  to  perform. 
At  the  same  time  there  was  decided  ataxy  in  the  left  hand. 
The  girl  was  able  to  play  the  piano  with  the  right  hand, 
but  could  not  do  so  with  the  left  ;  she  had  great  difficulty 
in  picking  up  a  pin  with  her  left  hand,  or  do  any  useful 
complex  action ;  yet  the  muscular  force,  .as  tested  with  the 
dynamometer,  was  quite  normal.  The  use  of  the  hand  for 
finer  movements  improved  only  gradually  after  sensation 
had  been  re-established. 

Yierordt  and  Heyd  have  shown  that  when  the  soles  of 
the  feet  of  a  healthy  person  are  rendered  ansesthetic  by 
the  prolonged  application  of  a  freezing  mixture  of  ice  and 
salt,  or  by  Richardson's  ether  spray,  ataxy  of  movements 
is  produced.  This  shows  that,  when  no  information  is 
given  by  the  nerves  of  the  feet  to  the  centres  of  co-ordina- 
tion, these  are  unable  to  act. 

Let  us  now  analyse  very  briefly  the  mechanism  by  which 
walking  is  rendered  possible  under  ordinary  circumstances, 
and  then  proceed  to  consider  the  mode  of  production  of 
ataxy  in  the  lower  extremities,  where  it  almost  invariably 


2^6  SCLEROSIS  OF  THE  SPINAL  CORD. 

occurs  first.  Walking  in  a  proper  manner  requires,  in  tlio 
first  instance,  the  integrity  of  the  entire  motor  zone  of  the 
brain  and  spinal  cord.  The  great  automatic  centre  of 
motor  power  and  muscular  nutrition  and  tonicity  resides  in 
the  large  ganglionic  cells  of  the  grey  anterior  horns  of  the 
spinal  cord,  some  of  which  are  of  sufiicient  size  to  be 
visible  to  the  naked  eye  when  coloured  with  carmine.  In 
these  cells  the  power  of  motion  is  produced,  and  they  send 
the  force  which  constantly  originates  in  them  to  the  motor 
nerves  and  muscles  by  means  of  Deiters's  processes  or 
axis-cylinders.  We  have,  therefore,  at  our  command  an 
instrument  of  motor  power  always  ready  to  act,  if  called 
upon  to  do  so.  The  volitional  impulses  for  this  originate 
in  the  hemispheres  of  the  brain,  and  more  particularly 
in  the  central  grey  convolutions  bordering  the  fissure  of 
Rolando.  These  automatic  and  volitional  centres  of  motion 
are  intimately  connected  with  one  another  by  a  commis- 
sure of  white  conducting  fibres,  known  as  the  pyramidal 
strands,  by  means  of  which  the  will  acts  on  the  medullary 
centres,  and  which  communicate  freely  all  the  way  down 
with  the  motor  cells  in  the  anterior  horns.  It  is,  how- 
ever, not  in  the  medullary  centres  that  the  action  of  the 
motor  nerves  and  muscles  is  co-ordinated  and  regulated. 
This,  on  the  contrary,  is  done  in  the  central  ganglia  of 
the  brain,  viz.,  the  corpus  striatum  and  thalamus  opticus, 
which  communicate  through  the  white  internal  capsule 
with  the  higher  motor  centres  above  and  the  lower  motor 
centres  further  down.  Of  these  the  corpus  striatum 
co-ordinates  motor  power,  while  the  optic  thalamus  co- 
ordinates sensory  impressions,  and  the  internal  capsule 
serves  as  a  conductor.  Both  central  ganglia  acting  in 
unison  have  the  special  function  of  rendering  move- 
ments which  are  intimately  connected  with  sensations, 
and  which  are  in  the  first  instance  only  excited  by  con- 
scious volitional  efforts,  gradually  mechanical  and  auto- 
matic.    The    object  of  this   contrivance  is  to    save   time 


SYMPTOMS  OP  TABES   SPINALIS.  247 

and  trouble  to  the  highest  portion  of  the  brain,  or 
the  grey  surface  of  the  hemispheres,  which  is  intended 
to  be  habitually  occupied  only  with  the  most  important 
manifestations  of  life.  Walking  and  all  other  complex 
movements  have  to  be  learnt  early  in  life  by  countless 
conscious  efforts  on  the  part  of  the  hemispheres  ;  and  full 
attention  is  necessary  in  the  beginning  to  enable  us  to 
carry  out  such  movements  in  a  proper  manner.  But  the 
older  we  grow,  the  more  frequently  we  have  directed 
our  minds  to  all  such  forms  of  action,  the  less  effort  will 
eventually  be  necessary  on  the  part  of  consciousness  and 
volition  ;  and  ultimately  all  such  movements  will  be  per- 
formed mechanically,  and  without  much,  if  any,  attention 
to  them  on  the  part  of  the  grey  surface  of  the  brain.  A 
man,  who  is  in  the  habit  of  writing  much,  never  thinks  of 
the  way  in  which  he  forms  his  letters  on  the  paper,  over 
which  his  pen  seems  to  fly  quite  mechanically.  The  same 
holds  good  for  the  various  kinds  of  needlework,  em- 
broidery, playing  the  piano,  the  violin,  dancing,  riding  on 
horseback,  singing,  decent  eating  and  drinking,  etc.  If, 
each  time  we  do  anything  of  that  sort,  a  conscious  effort 
were  necessary  for  all  the  different  parts  of  which  the 
action  is  composed,  the  time  at  our  disposal  would  not 
suffice  for  a  hundredth  part  of  the  work  which  we  actually 
get  through  in  life ;  and  some  forms  of  activity,  such  as 
finished  piano  and  violin  playing,  would  be  utterly  im- 
possible. The  act  of  walking,  indeed,  becomes  in  course 
of  time  so  automatic  that  in  general  no  attention  what- 
ever is  paid  to  it. 

In  order,  however,  that  the  central  ganglia  shall  be  able 
to  thus  minimise  the  work  which  has  to  be  done  in  life,  it 
is  necessary  that  they  should  constantly  receive  accurate 
information  of  the  position  of  our  limbs,  and  the  nature 
of  the  obstacles  with  which  the  latter  come  in  contact.  We 
may  be  able  to  walk  fast  enough  on  a  smooth  level  road  with- 
out thinking  about  it,  but  if  the  pavement  has  been  taken 


248  SCLEROSIS  OF  THE  SPINAL  COED. 

up,  or  we  have  to  walk  across  a  newlj  ploughed  field,  or  on 
the  edge  of  a  precipice,  or  on  a  narrow  bridge  or  plank  thrown 
across  a  stream,  or  in  a  crowded  thoroughfare  where  hansom- 
cabs,  omnibuses,  perambulators,  tricycles  and  foot-passengers 
jostle  each  other,  or  in  the  dark  on  a  staircase  with  which 
we  are  not  acquainted,  then  a  considerable  amount  of  at- 
tention is  required  for  overcoming  such  obstacles  in  our 
way  with  safety.  The  mere  impressions  conveyed  to  the 
central  ganglia  by  the  posterior  columns  are  then  no  longer 
sufficient,  but  the  aid  of  the  eyes,  or,  in  the  case  of  the 
dark  staircase,  of  the  hands  and  arms,  is  instinctively  called 
in,  in  order  to  supplement  the  ordinary  sensory  impressions 
by  special  information  and  subsequent  manoeuvring.  We, 
therefore,  under  those  circumstances  behave  like  the  ataxic 
does  habitually,  that  is  to  say,  we  use  our  eyes  as  crutches, 
and  manoeuvre  with  our  hands  and  arms  to  assist  us  ;  and 
even  then  we  do  not  walk  as  well  as  we  do  on  a  smooth,  level 
road  where  there  are  no  impedimenta  of  any  kind  to  be  over- 
come. The  ataxic,  therefore,  is  habitually  in  the  condition 
in  which  we  are  under  such  special  circumstances  as  I 
have  just  mentioned.  The  information  habitually  given  to 
the  central  ganglia  by  the  posterior  columns  is  not  available 
for  him,  because  those  columns  have  ceased  to  exist,  and 
the  various  groups  of  ganglionic  cells  can  therefore  no 
longer  be  combined  for  synergic,  orderly,  or  purposive  action. 
There  is  no  longer  any  harmony  between  the  muscles  which 
act  and  their  antagonists  which  regulate  the  action  ;  wrong 
groups  of  muscles  are  called  into  play,  which  impair  the 
action  instead  of  facilitating  it  ;  the  antagonists  act  too 
energetically,  and  those  muscles  which  produce  the  action 
have  therefore  to  redouble  their  efforts  in  order  to  arrive  at 
a  certain  result.  There  is,  therefore,  useless  expenditure 
of  nervous  force,  causiDg  fatigue,  which  latter  is  increased 
by  calling  in  the  aid  of  the  central  convolutions  bordering 
the  fissure  of  Kolando.  In  order  to  be  able  to  walk  at  all, 
the  ataxic   has  to  use  his  eyes  as  crutches,  and  his  arms 


SYMPTOMS    OF    TABES    SPINALIS.  249 

and  hands  as  manoeuvring-poles  ;  and  even  then,  when  he 
is  spending  all  the  reserve  forces  stored  up  in  the  nervous 
system,  he  will  court  failure,  and  stammer  with  his  feet. 

The  mode  of  production  of  locomotor  ataxy  thus  ap- 
pears satisfactorily  explained  ;  and  it  only  remains  for  us 
to  account  for  the  phenomena  of  static  ataxy  which  are 
generally  associated  with  the  former. 

The  cerebellum,  which  was  once  believed  to  be  the  seat 
of  the  reproductive  faculty  and  desire,  is  now  known  to  be 
the  centre  of  equilibration  of  the  body.  Removal  of  the 
cerebellum  in  an  animal  causes  static  ataxy  ;  the  animal 
cannot  keep  steady  on  its  legs,  but  staggers  about  as  if  it 
were  drunk.  It  is  not  paralysed,  and  endeavours  to  carry 
out  certain  movements,  but  there  is  an  utter  want  of  pre- 
cision, and  even  the  most  desperate  efforts  do  not  succeed 
in  steadying  it.  We  have  already  mentioned  (p.  182)  that 
one  portion  of  this  organ  prevents  us  from  falling  for- 
wards, another  from  falling  sideways,  and  from  constantly 
turning  round  in  a  circle,  while  a  third  is  intended  to  secure 
us  from  falling  backwards.  The  behaviour  of  animals 
deprived  of  their  cerebellum  in  fact  resembles  in  the  closest 
possible  manner  that  which  we  have  seen  to  occur  in  ataxy. 
The  erroneous  information  which  the  cerebellum  receives 
from  the  diseased  cord  may,  however,  be  to  some  extent 
corrected  by  sight  ;  and  this  accounts  for  the  fact  of  stand- 
ing being  so  much  more  difficult  when  the  eyes  are  closed 
(Romberg's  symptom),  as  well  as  for  the  other  phenomena 
of  static  ataxy.  Whether  the  paths  through  which  in- 
formation is  given  to  the  cerebellum  are  situated  in  Goll's 
columns,  in  which  case  the  road  would  be  somewhat  more  in- 
direct, or  in  the  direct  cerebellar  strands,  which  would  carry 
information  in  a  straight  line  to  the  cerebellum,  we  are  at 
present  not  in  a  position  to  determine.  We  may,  however, 
take  it  as  an  indisputable  fact  that  the  symptom  of  locomotor 
ataxy  is  caused  by  an  interruption  of  the  ^?«^/i5  between  the 
posterior  roots  and  the  central  ganglia  of  the  brain  through 


250  SCLEROSIS  OF  THE  SPINAL  CORD. 

sclerosis  of  the  posterior  columns,  and  that  static  ataxy  is  in 
its  turn  brought  abotit  hy  an  interruption  oj  the  paths  between 
the  posterior  roots  and  the  cerebellum,  through  sclerosis  either  of 
GolVs  columns  or  of  the  direct  cerebellar  strands. 

23.  Sensibility  in  the  second  stage  of  tabes. — a.  The  light- 
ning-pains have  been  already  so  fully  described  (p.  146)  that 
it  is  not  necessary  to  say  anything  more  about  them,  except 
that  they  may  continue  throughout  the  entire  second  period 
of  tabes.  In  some  cases  they  appear  to  increase  in  intensity 
and  frequency  of  occurrence  as  time  goes  on  ;  while  in 
others  gradually  longer  intervals  of  rest  are  noticed.  As 
a  rule  they  diminish  or  disappear  altogether  when  the 
second  period  begins  to  merge  into  the  third,  and  when  it  is 
to  be  supposed  that  most  or  all  the  fibres  which  are  con- 
cerned in  the  production  of  these  pains  have  been  destroyed. 
Sometimes  these  pains  leave  the  lower  limbs  and  attack  the 
arms,  as  time  goes  on  ;  which  is  to  be  accounted  for  by  the 
tendency  of  the  disease  to  spread  upwards  in  the  spinal 
cord.  When  all  the  fibres  in  the  lower  portion  of  the  cord 
which  transmit  the  sensation  of  pain  have  been  destroyed, 
anaesthesia  and  analgesia  take  the  place  of  lightning-pains  ; 
but  at  this  period  there  may  be  active  irritation  still  going 
on  in  the  upper  portion  of  the  cord,  causing  lightning-pains 
in  the  upper  extremities,  so  that  the  patient  is  no  better  off. 

b.  Numbness,  which  is  generally  slight  in  the  first  stage, 
is  habitually  more  pronounced  in  the  second.  The  patient 
complains  chiefly  of  numbness  in  the  feet  ;  and  when  asked 
to  describe  the  sensation  more  minutely,  says  that  there  is 
a  kind  of  heaviness  or  furriness,  as  if  they  had  gone  asleep  ; 
or  as  if  the  feet  were  in  thick  fur  boots,  or  rested  on  thick 
woolly  rugs  or  carpets  or  water-cushions.  The  contact  of 
slippers,  boots,  and  drawers  is  not  properly  felt.  The  degree 
of  this  numbness  varies  from  time  to  time,  is  worse  when 
a  change  in  the  weather  is  impending  or  during  storms, 
or  when  the  patient  is  fatigued  :  it  is  apt  to  spread  as  the 
disease  progresses,  and  gradually  invades  the  ankles,  the 


SYMPTOMS  OF  TABES  SPINALIS.  2.51 

legs,  thighs,  hips,  and  goes  up  to  the  waist,  where  it 
encounters  the  peculiar  form  of  tightness  which  has  already 
been  described  (p.  201).  In  the  upper  extremities,  on  the 
contrary,  the  numbness  is  habitually  perceived  in  the  third 
and  little  finger,  and  is  apt  to  spread  from  there  on  the  ulnar 
side  of  the  forearm  up  to  the  olecranon,  beyond  which  it 
often  does  not  pass  for  many  years.  It  also  affects  the 
entire  palm  of  the  hand,  while  numbness  in  the  lower  limbs 
is  generally  equally  pronounced  in  both  sides  ;  it  often 
remains  confined  to  one  of  the  upper  extremities  in  the 
region  just  mentioned,  and  sometimes  invades  the  other 
gradually  in  a  different  part,  so  that  the  thumb  and  first 
finger  are  particularly  affected.  It  generally  precedes  the 
symptom  of  ataxy  by  a  short  interval,  and  is  proportionate 
in  extent  to  the  degree  of  ataxy  which  may  be  present. 

Numbness  is  one  of  the  most  constant  symptoms  of  the 
second  period  of  tabes,  and  is  only  very  exceptionally  ab- 
sent. It  is  important  to  know  that  it  is  frequently  present 
without  any  form  of  anaesthesia  which  may  be  objectively 
determined.  Indeed,  it  is  a  symptom  per  se,  concerning 
which  we  have  to  rely  entirely  on  the  statement  of  the 
patient. 

c.  Ancesthesia,  or  loss  of  the  sense  of  touch  or  contact,  is 
a  frequent  symptom  at  this  stage  of  the  disease.  We  can 
determine  this  objectively  by  examination  of  the  patient  ; 
but  we  should  not  rely  too  implicitly  upon  his  statements 
unless  he  happen  to  be  a  particularly  intelligent  person. 
In  people  of  ordinary  intellect  a  second  examination  gives 
occasionally  entirely  different  results  from  those  of  the  first  ; 
and  it  must  be  confessed  that  no  examination  takes  more 
time,  is  more  tedious  to  both  patient  and  doctor,  and,  even 
when  systematically  performed,  eventually  more  uncertain 
in  its  results  than  that  for  anaesthesia  and  its  various  degrees. 

It  is  important  that  a  definite  method  should  be  fol- 
lowed in  testing  a  patient  for  anaesthesia,  as  the  rough- 
and-ready  mode  which  is  often  thought  all  that  is  required, 


252  SCLEROSIS  OF  THE  SPINAL  CORD. 

viz.,  to  prick  the  patient  with  a  pin,  is  by  no  means 
sufficient.  When  we  wish  to  discover  slight  degrees  of 
anaesthesia,  we  request  tlie  patient  to  close  his  eyes,  and 
then  very  gradually  approach  our  first  finger  to  that 
part  of  his  skin  which  we  intend  to  examine.  We 
satisfy  ourselves  first  that  there  is  no  considerable  dif- 
ference of  temperature  between  the  examiner  and  the  one 
to  be  examined  ;  our  own  hand  must  never  be  colder 
than  the  patient's  skin,  as  the  sensation  of  cold  may 
still  be  keenly  felt  when  the  perception  of  ordinary 
contact  is  lost.  As  soon  as  we  ourselves  perceive  the 
least  sensation  of  contact,  the  patient  should  do  the 
same.  We  must  avoid  rubbing  or  pressing  the  skin,  or 
even  a  sudden  approach,  as  all  such  manoeuvres  imply 
more  than  simple  touch.  After  satisfying  ourselves 
whether  the  patient  feels  our  touch  or  not,  we  next  ascer- 
tain whether  he  feels  a  difference  between  wet  and  dry, 
smooth  and  rough  ;  and,  in  the  hand  and  fingers,  whether 
the  patient  can  tell  the  nature  and  shape  of  certain  familiar 
objects,  such  as  coins,  knives,  pens,  pins,  etc. ;  we  also 
examine  the  patient  with  Weber's  compasses,  or  sesthesio- 
meter,  remembering  the  normal  distances  for  the  per- 
ception of  the  two  separate  points  of  the  instrument, 
which  vary  from  half  a  line  on  the  tip  of  the  tongue,  and 
one  line  on  the  volar  surface  of  the  third  phalanx  of 
the  fingers,  to  two  inches  and  a  half  in  the  arm  and 
thigh.  In  order  to  test  the  common  sensibility  of  the 
feet,  we  let  the  patient  stand  on  a  soft  rug  and  a  bare  board 
alternately,  likewise  with  his  eyes  closed,  and  ascertain 
whether  he  feels  any  difference  in  them. 

Loss  of  tactile  sensibility  occurs  generally  some  time 
before  the  sensibility  to  pain  or  to  cold  is  diminished.  It  is 
chiefly  found  in  the  soles  of  the  feet  and  the  palms  of  the 
hands,  and  seems  proportionate  in  degree  to  the  distance 
at  which  the  parts  are  from  the  posterior  roots.  It  is 
therefore  more  marked  in  the  foot  than  in  the  leg  ;  more 


SYMPTOMS  OF  TABES  SPINALIS.  253 

in   the   leg  tJhan  in  the  thigh  ;   more  in   the   fingers   and 
hand  than  in  the  arm  and  shoukler,  etc. 

Anaesthesia  may  also  be  present  in  the  entire  sphere  of 
the  fifth  nerve.  It  is  occasionally  confined  to  one  side  of 
the  body,  and  may  appear  in  irregular  patches.  The 
patient  is  unable  to  take  any  special  object  out  of  his 
pockets,  if  there  are  several  different  things  in  them  ;  he 
may  bring  out  a  pencil-case  or  knife  when  he  wants  a 
shilling,  etc.  The  sense  of  touch  may  also  be  perverted, 
so  that  simple  contact  feels  like  pain,  or  sends  a  shiver 
through  the  patient,  who  may  continue  to  feel  it  for  several 
minutes  after  the  touch  has  been  made. 

Where  a  tabid  patient    has   become    totally  blind  and 
stone-deaf,    he  may  still    entertain   some    communication 
with  the    outer  world  by    means   of   the   sense  of  touch. 
Strlimpell  has  seen  a  case  where  only  by  touching  the  fore- 
head the    man    could   be    made  to  understand    anything. 
One  letter  after  another  was  traced  on  the  forehead  with 
the  finger  ;  and  the   patient    had    gradually    gained   con- 
siderable facility  in  making  out  such  words.     He  at  once 
pronounced  aloud  the  letter  which  had  been  traced  ;  if  it 
was    correct,  another  letter  was   traced,  but,  if  incorrect, 
the  hand  was  drawn   across   the  forehead,   and  the   letter 
repeated  until  he  made  it  out.     If  a  word  or  sentence  was 
finished,  a  simple  tap  on  the  forehead  informed  him  of  it. 
A  tap  also  meant  "yes,"  while  drawing  the  hand  across 
meant  "no  "  or  "  wrong."     It  was  thus  possible,  with  time 
and  patience,  to  have  some  conversation  with  this  man.    As 
he  was  an  intelligent  fellow,  he  guessed  most  words  after 
one  or  two  letters  had  been  traced ;  for  instance,  when  at  the 
visit  of  the  physician   "  d-o-"  had  been  traced,  he  at  once 
said,  "I'm  sure  it  is  the  doctor!      Good  morning,  doctor; 
how  do    you    do  ? "      Curiously   enough    he  guessed   the 
letters  traced  by  the  nurse's  hand  much  better  than  those 
by  the   doctor,  probably    from   the   former    corresponding 
more  witli  his   own  previous    way  of  writing.     He  often 


254:  SCLEROSIS  OF  THE  SPINAL  CORD. 

inquired  after  the  weather,  the  time  of  day,  etc.  ;  other- 
wise he  lay  quietly  in  bed,  with  his  hands  covering  the 
face,  apparently  in  order  to  gain  a  certain  amount  of  con- 
sciousness of  his  body. 

Schiff  has  shown  that  tactile  impressions  are  trans- 
mitted to  the  brain  exclusively  by  the  posterior  columns 
of  the  cord.  Division  of  these  columns  in  rabbits,  in 
front  of  that  part  which  gives  rise  to  the  nerves  for  the 
hind  legs,  prevents  any  tactile  impressions  made  on  those 
legs  from  being  perceived  by  the  animals ;  while,  on  the 
other  hand,  division  of  the  whole  cord,  with  the  only  ex- 
ception of  the  posterior  columns,  leaves  tactile  sensibility 
unimpaired. 

d.  Analgesia,  or  loss  of  the  sensation  of  pain,  is  likewise 
common  at  this  period.  Sensibility  to  pain  is  examined  by 
pricking  the  patient  with  a  pin,  pinching  him,  and  by 
applying  the  different  forms  of  electricity.  With  regard 
to  the  latter,  both  the  induced  and  constant  current  may  be 
employed.  The  best  mode  of  using  faradisation  is  to  apply  a 
perfectly  soft  faradic  wire  brush  with  a  large  surface  (such 
as  made  for  me  by  Coxeter  and  Son)  to  the  point  to  be  ex- 
amined, while  another  moistened  electrode  is  placed  on  the 
sternum  or  the  nape  of  the  neck.  The  minimal  current - 
strength  at  our  disposal  is  then  applied,  and  this  is  gra- 
dually increased  until  a  decided,  although  slight,  sensa- 
tion of  pricking  and  heat  is  noticed.  The  distance  of 
one  coil  from  the  other  is  then  read  of£  at  the  stem  pro- 
vided for  this  purpose,  and  compared  with  the  other  side 
of  the  body  of  the  patient  and  healthy  averages.  The 
continuous  current  has  to  be  applied  by  two  moistened  con- 
ductors, the  large  anode  being  placed  on  the  sternum  or 
the  nape  of  the  neck,  and  the  smaller  cathode  on  the  point 
to  be  examined.  As  soon  as  a  feeling  of  heat  and  pricking 
is  experienced  under  the  cathode,  the  number  of  milli- 
amperes,  or  fractions  of  such,  is  read  off  at  the  galvanometer, 
and  compared  with  the  corresponding  part  of  the  other  side. 


SYMPTOMS  OF  TABES  SPINALIS.  255 

and  with  healthy  averages.  This  mode  of  examination 
yields  the  most  certain  results  ;  but  it  takes  up  a  good 
deal  of  time,  and  cannot  be  carried  out  by  any  but  specially 
skilled  observers. 

Loss  of  the  sensibility  to  pain  is  generally  a  later  symp- 
tom than  anagsthesia,  probably  because  tactile  impressions 
are  not  so  keen  as  those  giving  actual  pain  ;  so  that  the 
latter  may  still  be  perceived  at  a  period  when  the 
simple  sense  of  touch  appears  to  have  already  vanished. 
Cruveilhier  mentions  the  case  of  such  a  patient  who  frac- 
tured his  leg,  and  neither  at  the  time  of  the  accident  nor 
afterwards  felt  any  pain  whatever. 

Analgesia  is  frequently  incomplete.  Thus,  the  prick 
of  a  pin  may  be  felt  as  a  simple  touch,  while  the  patient 
does  not  feel  the  head  of  the  pin  at  all.  If  the  excitant 
used  is  very  powerful,  pain  may  still  be  felt  when  ordinary 
painful  impressions  are  no  longer  resented.  This  holds 
good  more  particularly  for  the  proceeding  known  as  faradi- 
sation of  the  skin,  which,  when  a  powerful  current  is  used, 
is  almost  invariably  felt,  even  in  the  third  period  of  the 
disease.  It  may  even  then,  if  continued  for  some  time, 
rouse  any  feeble  remnant  of  sensibility  which  may  be  left, 
so  that  sensibility  to  ordinary  touch,  or  the  prick  of  a  pin, 
returns  for  a  time.  It  seems  as  if  the  few  remaining 
healthy  nerve-tabes,  which  may  still  exist  at  different  levels 
of  the  posterior  roots  or  columns,  were  by  such  a  proceed- 
ing shaken  up  from  their  habitual  torpor.  Sensibility,  thus 
restored,  however,  generally  disappears  again  a  few  hours 
afterwards,  and  a  dead  level  of  analgesia  is  re-established  ; 
nor  does  it,  at  the  time  when  faradisation  is  used,  come 
back  at  any  other  place,  except  in  the  one  which  has  been 
directly  touched  by  the  brush.  This  is  a  point  of  differ- 
ence between  tabid  and  hysterical  anaesthesia,  as  in  the 
latter  we  may,  by  faradisation  of  the  skin  of  a  limited 
area  of  the  forearm,  restore  all  forms  of  sensation  in  an 
entire  side  of  the  ))ody,  and  that  more  or  less  permanently. 


256  SCLEROSIS  OF  THE  SPINAL  COED. 

About  this  time  we  may  also  observe  the  peculiar  symp- 
tom of  ancBSthesia  dolorosa.  This  sign,  which  appears 
prima  facie  unintelligible,  is  owing  to  two  different  con- 
ditions, viz.,  first  a  considerable  diminution  of  sensibility, 
and  simultaneous  hypersesthesia  produced  by  unusually 
powerful  stimulants.  If,  for  instance,  a  portion  of  the  skin 
which  is  no  longer  sensitive  to  touch  is  strongly  pinched, 
this  pinch  will  not  only  be  felt,  but  will  even  be  felt  more 
unpleasantly  than  if  the  skin  were  in  its  normal  condition  ; 
while  at  the  same  time  a  special  feeling  of  burning  is  ex- 
perienced, which  is  quite  unbearable  to  the  patient.  A 
similar  state  may  be  artificially  induced  by  making  a  leg 
"  go  to  sleep,"  through  squeezing  the  sciatic  nerve  between 
the  sciatic  notch  and  the  edge  of  a  chair.  We  have  then 
anaesthesia  of  the  skin  ;  but  if  the  latter  be  pinched,  there 
is,  in  addition  to  the  pins  and  needles,  a  peculiarly  un- 
pleasant burning  sensation,  showing  that  the  sentient  nerves 
have  undergone  a  peculiar  modification. 

The  curious  phenomenon  of  delayed  sensation  is  chiefly 
observed  where  there  is  analgesia,  and  less  where  there  is 
common  anaesthesia.  The  impression  is  then  experienced 
from  one  to  five,  seven,  and  even  ten  seconds  after  it  was 
made.  This  delay  in  perception  is  greater  in  proportion 
to  the  distance  of  the  part  acted  upon  from  the  posterior 
roots. 

How  can  we  physiologically  explain  this  curious  symp- 
tom ?  As  the  rate  of  transmission  of  nervous  power  in 
man  is  about  forty  yards  per  second,  an  impression  made 
upon  any  part  of  the  body,  however  distant  from  the 
centre,  is  practically  perceived  at  the  same  instant  that  it 
is  made.  But  in  tabes  there  are  impediments  to  trans- 
mission. Unless  there  were  peripheral  neuritis  at  the  same 
time,  we  would  expect  the  impression  to  travel  up,  with  its 
normal  rapidity,  as  far  as  the  spinal  ganglia  ;  but  in  the 
posterior  roots  an  obstacle  is  encountered,  which  is  likewise 
present  in  what  remains  of  the  posterior  columns.     It  is 


SYMPTOMS  OF  TABES  SPINALIS.  257 

probable  that,  although  the  central  grey  matter  of  the  cord 
is,  according  to  Schiff,  ^esthesodic,  yet  the  transmission 
of  impressions  to  the  brain  would  in  general  rather  pass 
through  the  posterior  columns  than  the  central  grey  matter, 
for  the  sake  of  increased  speed.  In  the  central  grey  matter 
the  road  is  more  encumbered,  as  there  the  impression  must 
travel  from  one  ganglionic  cell  to  another  by  means  of 
Deiters's  prolongations,  which  connect  one  cell  with  another, 
while  the  transmission  along  the  course  of  straight  nerve- 
tubes  in  the  posterior  columns  must  be  infinitely  more  rapid. 
In  tabes,  however,  many,  or  most  of  the  fibres  of  the  pos- 
terior columns  have  been  destroyed,  and  are  replaced  by  con- 
nective tissue  which  does  not  conduct  at  all.  We  have, 
therefore,  a  similar  condition  as  if,  in  a  galvanic  battery, 
the  conducting  copper  wires  had  been  replaced  by  ordinary 
twine,  which  is  no  conductor.  The  current  would,  there- 
fore, seek  another  way,  although  it  might  be  much  more 
roundabout  than  the  direct  road  which  has  been  blocked  up. 
In  the  cord  this  road  passes  through  the  central  grey 
matter  ;  and  it  may  be  easily  imagined  that  if  there  should 
be  likewise  impediments  in  the  way  there,  the  transmission 
would  then  reach  its  extreme  limit  of  delay.  We  have  seen 
(p.  22)  that  the  posterior  cornua,  and  the  place  of  junction 
between  the  anterior  and  posterior  cornua  and  Clarke's  vesi- 
cular columns,  are  frequently  found  affected  in  tabes,  and 
these  are  just  the  portions  of  the  central  grey  matter  which 
are  more  particularly  concerned  with  sensation.  Should 
they  be  entirely  destroyed,  in  addition  to  the  posterior 
columns,  it  stands  to  reason  that  any  transmission  of  sensi- 
tive impressions  to  the  brain  is  rendered  impossible. 

e.  Loss  of  the  Sense  of  Temper atnre. — This  sense  is  best 
examined  by  applying  test-tubes  filled  with  hot,  tepid,  and 
cold  water,  to  the  skin.  A  test  recommended  by  Erb  is  to 
blow  on  the  patient's  skin  from  different  distances  ;  blowing 
near  is  felt  warm,  and  blowing  from  afar  gives  an  impres- 
sion   of    cold.     In    cold  weather   the   impression   of   any 

s 


258  SCLEROSIS  OF  THE  SPINAL  CORD. 

metallic  objects  which  are  at  hand  may  be  utilised.  Ice 
and  Richardson's  ether  spray  may  also  give  useful  indica- 
tions. Eulenburg  has  constructed  a  special  instrument  for 
conducting  such  investigations,  which  he  calls  the  therm- 
cesthesiometer,  which  may,  however,  in  general  be  dispensed 
with. 

Persons  in  good  health  are  able  to  distinguish  with 
certainty  a  difference  of  one,  or  even  half,  a  degree- 
Objects  which  are  warmer  than  93°  give  a  sensation  of 
heat,  and  such  as  are  below  90°  feel  cold.  This  faculty 
of  distinguishing  different  temperatures  remains  occasion- 
ally unimpaired  in  the  tabid,  although  they  may  have  lost 
all  other  kinds  of  sensations.  Topinard  relates  the  case  of 
a  patient  who  was  affected  by  double  amaurosis,  absolute 
anaesthesia  and  analgesia,  with  ataxy  of  a  severe  degree, 
and  who  had  only  the  sensation  of  heat  and  cold  left  to  tell 
him  that  he  still  had  his  limbs.  Sometimes  his  legs  would 
be  jerked  out  of  bed  by  spasms  which  he  did  not  feel,  and 
which,  being  blind,  he  could  not  see.  Then,  after  a  time, 
a  sensation  of  cold  would  creep  upon  him,  and  the  poor 
fellow  would  ask  whether  anything  was  the  matter  with 
his  legs.  This  patient  lived  only  by  his  memory,  as  he  had 
lost  the  consciousness  of  his  body.  But  the  sense  of  tempe- 
rature may  also  be  wanting.  Leyden  mentions  the  case  of 
a  patient  who  prepared  a  warm  bath  for  himself,  and  not 
being  able  to  distinguish  between  heat  and  cold,  made  it 
very  hot,  and  was  severely  scalded  on  going  into  it. 

It  is  a  singular  circumstance  that  the  sensibility  to  cold 
persists  longer  in  tabes  than  almost  any  other  form  of 
sensibility.  Indeed,  it  is  frequently  found  exaggerated  at 
a  time  when  the  sense  of  touch  is  entirely  lost,  and  when 
there  is  already  a  considerable  degree  of  analgesia.  Thus 
the  contact  of  a  piece  of  metal  or  of  a  sponge  saturated 
with  cold  water  may  be  perceived,  when  neither  ordinary 
touch,  nor  the  prick  of  a  pin,  nor  a  gentle  electric  current  are 
felt  any  longer.    The  impression  of  cold  is  indeed  often  so 


SYMPTOMS  OF  TABES  SPINALIS.  259 

sudden  and  surprising  to  the  patient  that  extensive  reflex 
movements  are  caused  in  consequence.  It  is  difficult  to 
account  for  this  curious  symptom.  Vulpian  thinks  that 
it  may  be  owing  either  to  an  undue  degree  of  excitability 
of  the  grey  matter  of  the  cord,  where  such  sensations  are 
elaborated,  or  to  exaggerated  vibrations  produced  in  the 
cutaneous  nerves,  in  consequence  of  traversing  posterior 
root-fibres  which  are  in  a  state  of  irritation.  This,  how- 
ever, is  really  no  explanation,  but  only  a  different  way  of 
stating  the  fact  that  the  excitability  to  cold  is  exaggerated  ; 
for  why  should  not  the  irritation  of  the  central  grey  matter 
or  the  posterior  roots  give  rise  to  exaggeration  of  the  other 
forms  of  sensibility  ?  Other  observers  have  thought  that 
there  are  special  sets  of  nerve-fibres  for  perceiving  tempera- 
ture, and  others  for  pain  and  contact.  This  is  also  most 
unlikely  ;  for  if  there  were  any  such,  why  should  they 
escape  the  morbid  influence  ?  Another  theory  is  that  there 
are  certain  extra-medullary  centres  which  serve  for  the  re- 
ception and  elaboration  of  thermic  impressions,  and  that 
these  are  not  invaded  by  the  sclerosis.  This  is  equally  un- 
satisfactory, for  we  may  well  ask  why  should  they  be  thus 
exempt  ;  and  should  also  be  obliged  to  assume  the  exist- 
ence of  special  intra-meduUary  centres  for  the  perception 
of  beat  as  well  as  cold.  This  at  once  reduces  the  pro- 
position to  an  absurdity.  We  must,  therefore,  for  the 
present  be  satisfied  with  knowing  that  cold  is  one  of  the 
few  stimulants  the  response  to  which,  in  tabes,  is  gene- 
rally increased,  instead  of  diminished. 

It  should  also  be  noted  that  the  transmission  of  the  im- 
pression of  cold  is  less  delayed  than  that  of  touch  or  pain. 
In  advanced  cases,  however,  it  is  likewise  delayed,  and  more 
especially  so  if  the  impression  be  made  nearer  to  the  peri- 
phery than  to  the  centre. 

f.  The  sense  of  locality  may  be  examined  by  touching  or 
pricking  the  patient  in  a  certain  spot,  his  eyes  being  at  the 
8ame  time  closed,  and  then  letting  him  indicate  the  point 

s  2 


260  SCLEROSIS  OF  THE  SPINAL  CORD. 

touched  or  pricked  with  his  finger.  This  modification  of 
sensibility  is  likewise  frequently  found  to  be  diminished  in 
the  second  stage  of  tabes.  Diseased  structures  conduct  im- 
pressions made  on  the  skin,  not  in  the  definite  mode  in  which 
this  is  done  by  healthy  structures,  but  in  an  uncertain  and 
halting  kind  of  manner  which  does  not  allow  of  a  clear 
perception  of  the  locality  of  the  point  which  may  have  been 
touched.  It  is  a  curious  circumstance  that  if  the  patient 
makes  a  mistake  in  localising  an  impression,  he  almost 
invariably  points  to  a  place  nearer  the  centre  than  the  one 
which  has  been  touched.  He  is  sometimes  wrong  to  the 
extent  of  several  inches. 

g.  The  sense  of  pressure  may  be  investigated  by  putting 
different  weights  on  various  parts  of  the  patient's  body, 
when  he  will  occasionally  be  unable  to  tell  the  difference 
between  an  ounce  and  a  two-ounce  weight.  Eulenburg 
has  constructed  a  special  instrument  for  investigating  this 
peculiarity,  which  he  has  called  the  barcesthesiometer.  This 
shows  differences  in  pressure  by  the  movements  of  an  index 
on  a  dial.  The  ordinary  post-office  scales  and  weights  will 
however,  generally  be  found  sufficient.  Coins  or  billiard 
balls  of  different  weights  are  also  useful.  This  sense  is 
equally  affected  in  tabes  as  the  other  modes  of  sensibility. 

h.  Tickling  the  soles  of  the  feet,  the  knees  and  other 
parts  is  occasionally  not  perceived  at  all,  while  in  other 
patients  a  curious  thrill  and  shiver  is  sent  through  the 
whole  body,  the  impression  of  which  may  last  for  a  con- 
siderable time. 

The  singular  manner  in  which  these  different  forms  or 
kinds  of  sensibility  are  affected  in  tabes  has  led  some 
pathologists  to  the  conclusion  that  there  are  different 
nerves  for  each  one  of  them — some  for  contact,  others  for 
pain,  others  for  temperature,  tickling  and  so  on  ;  and  Brown- 
Sequard  has  distinguished  the  alarming  number  of  twenty- 
two  different  kinds  of  central  nerve-fibres.  There  is,  how- 
ever, no  evidence  whatever  to  show  that  all  these  different 


SYMPTOMS  OF  TABES  SPINALIS.  261 

or  special  nerve-fibres  with  highly  specialized  physiological 
attributes  exist  ;  on  the  contrary,  it  appears  certain  that 
the  same  conductors  may  transmit  to  the  brain  all  the 
various  kinds  of  impressions  which  may  be  made  on  the 
peripheral  expansions  of  the  sentient  nerves. 

Vulpian  has  shown  that  not  every  one  of  the  individual 
sentient  nerve-tubes  ascends  to  the  cord  through  the  spinal 
ganglia,  since  the  bulk  of  the  posterior  root  is  not  the  same 
throughout  its  extent.  If  there  were  a  real  continuity  of 
fibres  all  the  way  up,  then  we  should  no  doubt  see  definite 
and  absolute  aneesthesia  involving  all  the  different  kinds 
of  sensibility  in  certain  well-defined  areas,  while  in  other 
equally  well  defined  areas  all  forms  of  sensation  would  con- 
tinue. Such,  however,  is  not  the  case.  The  connexion 
between  the  peripheral  fibres  and  the  posterior  root-fibres  is 
therefore  only  indirect,  so  that  every  root-fibre  may  be  caused 
to  vibrate  by  impressions  made  on  any  peripheral  fibre. 
When  there  has  been  destruction  of  root-fibres  through 
sclerosis,  the  vibration  which  any  peripheral  fibre  may  con- 
vey to  the  cord  and  brain  cannot  be  so  keen  as  it  must  be 
when  all  root-fibres  are  in  full  physiological  activity.  If, 
therefore,  the  impression  which  is  made  be  slight,  it  will 
not  be  perceived,  while  a  more  vigorous  impression  may 
still  be  felt.  We  are,  therefore,  led  to  the  opinion  that  the 
peripheral  afferent  fibres,  as  well  as  the  posterior  roots  and 
nerve-cells  in  the  spinal  ganglia,  as  well  as  the  posterior  grey 
matter  of  the  cord,  have  the  same  physiological  properties  ; 
and  that  the  differences  observed  are  more  in  the  nature 
of  the  excitants  or  stimulants  used,  than  in  the  different 
portions  of  nerve-structures  themselves.  Different  stimu- 
lants cause  different  molecular  vibrations  in  the  nerve-tubes 
as  well  as  in  the  grey  cells  ;  and  this  is  the  reason  why 
contact,  painful  impressions,  heat,  cold,  etc.,  are  differently 
appreciated. 

i.  Muscular  sensibility  is  likewise  affected  at  this  stage. 
Squeezing   the   muscles  and  faradising  them  by  a  weak 


262  SCLEROSIS  OF  THE  SPINAL  CORD. 

or  moderate  current,  with  the  aid  of  moistened  conductors, 
is  often  not  perceived.  The  impairment  of  this  sense  is 
no  doubt  intimately  connected  with  another  curious  symp- 
tom which  is  often  observed,  viz.,  that  the  patient  has 
enthely  lost  the  faculty  of  knowing  where  his  legs  or 
arms  are.  He  appears  to  lose  them  in  bed  ;  he  cannot  tell 
whether  they  are  flexed  or  extended,  crossed  or  lying  side 
by  side,  or,  if  crossed,  which  is  crossed  over  the  other.  He 
has  actually  to  search  for  his  legs  with  his  fingers  from  the 
hips  downwards,  in  order  to  be  able  to  give  an  account  of 
their  position.  It  is,  however,  probable  that  the  sense  of 
the  position  of  the  limbs  does  not  exclusively  reside  in  the 
muscles,  but  also  to  some  extent  in  the  skin,  the  joints,  and 
the  bones. 

24.  Other  reflexes  than  the  hnee-jerk  may  likewise  be  much 
diminished  or  lost.  Cutaneous  or  superficial  reflexes  as 
a  rule  keep  pace  with  the  state  of  sensibility.  Where 
the  latter  is  much  affected,  these  reflexes,  more  especially 
those  elicited  by  tickling  the  soles  and  the  knees,  are  apt 
to  become  sluggish.  The  cremasteric,  abdominal,  and  epi- 
gastric reflexes  are  likewise  often  found  to  be  lost  in  the 
later  stages  of  the  disease.  The  intra-ocular  sympathetic 
reflex  is  generally  absent, — that  is  to  say,  irritation  of  the 
skin  of  the  neck  does  not  enlarge  the  pupil. 

The  reflexes  which  continue  unimpaired  longer  than  any 
other  are  those  which  are  produced  by  the  influence  of  cold. 
If  we  touch,  for  instance,  the  inner  surface  of  the  thigh 
with  a  sponge  full  of  cold  water,  or  a  cold  metal,  the  limb  is 
at  once  withdrawn,  and  sometimes  this  reflex  takes  place  a 
few  seconds  before  the  sensation  of  cold  is  perceived. 
There  may  be  quite  a  series  of  flexions  and  extensions  of 
the  legs  and  thighs,  which  resemble  the  movements  of 
attempted  escape  in  animals.  Occasionally  it  is  sufficient 
simply  to  uncover  the  patient  when  he  is  in  bed,  to  make 
his  legs  move  about,  or,  as  Vulpian  has  aptly  called  it, 
gesticulate  in  all  directions.     If  the  sense  of  temperature 


SYMPTOMS  OF  TABES  SPINALIS.  263 

is,  however,  entirely  lost,  these  reflexes  can  no  longer  be 
elicited.  All  the  other  tendon  reflexes  disappear  at  a  com- 
paratively early  stage  of  the  malady. 

25.  The  urine  is  in  the  beginning  of  the  second  period 
of  tabes  occasionally  quite  normal.  In  other  cases  there  is 
an  excess  of  phosphates  and  lithates  ;  but  what  seems 
more  important  is  the  presence  of  sugar,  which  I  have 
noticed  in  several  cases.  I  have  generally  found  this  com- 
bined with  the  presence  of  an  excess  of  urea,  and  the 
specific  gravity  of  the  urine  has  under  these  circumstances 
ranged  between  1030  and  1037.  The  quantity  of  sugar 
in  the  urine  appeared  to  vary  considerably,  amounting 
occasionally  to  nearly  200  grains  in  the  pint.  I  have  also 
known  patients  to  discharge  sugar  habitually  for  two  or 
three  years,  and  then  to  cease  doing  so,  showing  that  it  is 
glycosuria  rather  than  diabetes. 

In  other  cases  the  urine  contains  my  co-pus  and  leuco- 
cytes, and  is  liable  to  speedy  ammoniacal  fermentation ;  but 
these  graver  symptoms  occur  more  especially  in  the  terminal 
stage  of  the  disease. 


III.  Symptoms  of  the  Third  or  Terminal  Stage  of  Tabes 
Spinalis. — In  this  stage  the  ataxy  of  movement  is  re- 
placed by  paresis  or  paralysis  ;  and  there  is  a  proportionate 
increase  in  the  severity  of  all  the  other  symptoms,  with  the 
only  exception  of  lightning  and  other  pains,  which  as  a  rule 
vanish  when  all  the  fibres  of  the  posterior  columns  have 
been  destroyed.  We  observe  then  more  or  less  complete 
paralysis  of  the  bladder  and  bowels,  absolute  impotency 
and  loss  of  sexual  desire,  a  considerable  degree  of  muscular 
atrophy  and  arthropathy,  and  tendency  to  bedsores.  Brain- 
disease  is  now  likewise  apt  to  appear,  and  this  requires 
special  consideration. 

26.  Late  Brain- Troubles  in  Tabes. — In  some  cases  the 
intellect   continues  unclouded  to  the    very  last,  while  in 


264  SCLEROSIS  OF  THE  SPINAL  CORD. 

others  it  becomes  affected  in  a  variety  of  ways.  It  is 
not  uncommon  to  find  that  patients,  when  they  ultimately 
lose  all  hope  of  recovery,  become  extremely  depressed  in 
spirits.  I  have  known  such  a  patient  to  cry  all  day  long 
like  a  child.  In  other  cases  there  is  melancholia  ;  the 
patient  becomes  taciturn,  shy,  refuses  to  speak,  or  to  take 
notice  of  anything  ;  and  this  condition  may  alternate  with 
fits  of  maniacal  excitement.  Where  there  is  any  hereditary 
predisposition  to  mental  affections,  this  is  more  particu- 
larly likely  to  occur. 

I  will  now  shortly  relate  two  cases  of  mental  affection 
during  the  last  stage  of  tabes,  which  were  under  my  care 
some  time  ago  : — 

Case  70. — A  gentleman,  aged  forty-five,  single,  con- 
sulted me  in  September,  1880.  He  had  had  syphilis  in 
1869,  and  obstinate  secondary  symptoms  in  the  throat  and 
skin.  He  told  me  that  he  had  swallowed  hundredweights 
of  iodide  of  potassium  and  mercury,  and  had  lately  had  a 
hundred  inunctions  at  Aix-la-Chapelle,  without  the  slightest 
benefit.  Two  years  ago  he  had  double  vision  from  para- 
lysis of  the  right  rectus  externus,  and  shooting  pains  in  the 
lower  extremities.  Soon  afterwards  he  lost  the  use  of  his 
legs,  and  the  power  over  the  bladder.  He  has  still  some 
amount  of  muscular  force  in  the  legs,  but  is  utterly  unable 
to  walk  or  to  stand.  There  is  great  numbness,  anaesthesia 
and  analgesia  in  the  legs.  The  urine  is  habitually  drawu 
off  by  the  catheter,  and  there  is  such  a  degree  of  urethral 
anaesthesia  that  he  does  not  feel  the  introduction  of  the  in- 
strument. The  urine  is  ammoniacal,  and  contains  a  large 
quantity  of  ropy  mucus.  On  coughing  and  sneezing  there 
is  always  an  involuntary  spasmodic  ejection  of  urine.  The 
bowels  are  confined,  and  he  does  not  feel  the  approach  of 
any  action,  so  that  the  evacuation  generally  takes  place 
before  he  has  time  to  reach  the  commode. 

The  patient  improved  for  a  time  considerably  under 
treatment,  which  consisted  chiefly  of  the  administration  of 


SYMPTOMS  OF  TABES  SPINALIS.  265 

nitrate  of  silver,  ergot  of  rve,  and  electricity.  The  urine 
became  at  first  feebly,  and  afterwards  fairly,  acid  ;  the 
patient  regained  the  power  over  the  bladder  to  such  an  ex- 
tent that  he  passed  six  or  eight  ounces  of  urine  in  a  stream 
by  himself,  and  retained  it  a  great  deal  better.  The  action 
of  the  bowels  was  also  much  improved.  He  now  felt  a 
warning  before  a  motion  was  going  to  take  place,  and  got 
sufiicient  notice  to  avoid  mishaps.  The  sensation  in  the 
legs  likewise  improved  ;  he  began  to  localise  impressions, 
felt  stronger  generally,  had  a  good  appetite,  and  slept  splen- 
didly. He  could  walk  tolerably  well,  when  supported  on 
both  sides.  At  this  time  there  occurred  unfortunately  a 
change  in  the  attendance  on  the  patient,  with  the  result 
that  he  was  induced  to  take  sherry  freely,  beginning  early 
in  the  morning,  and  going  on  throughout  the  day.  This 
interfered  at  first  with  his  sleep,  and  he  became  so  restless, 
that  he  was  in  and  out  of  bed  all  night.  On  November 
20th,  regular  hallucinations  commenced  which  were  to  a 
great  extent  of  a  terrifying  nature.  He  screamed  "  murder  " 
in  a  stentorian  voice,  so  that  it  was  heard  at  a  considerable 
distance.  He  told  me  that  his  nurse  had  entered  into  a 
conspiracy  with  some  other  people  to  poison  him  ;  and  that 
even  his  dog  had  been  drugged.  He,  therefore,  refused 
food  of  any  description.  I  tasted  some  of  his  tea,  which 
was  standing  by  his  bedside,  and  which  he  said  was  poi- 
soned, in  order  to  show  him  how  groundless  his  fears  were  ; 
and  after  that  he  drank  some  of  it.  The  next  day,  how- 
ever, he  insisted  on  the  nurse  being  discharged,  saying  : 
"  The  rascal  told  a  lot  of  lies  !  "  He  then  began  to  suspect 
myself,  said  that  I  was  as  bad  as  the  rest,  the  medicines 
prescribed  were  poisons,  and  refused  to  answer  any  ques- 
tions or  to  enter  into  any  argument.  I  now  retired  from  the 
case,  and  handed  the  patient  over  to  a  physician  who  had 
previously  attended  him.  In  the  meantime  his  relations 
were  telegraphed  for,  and  on  their  arrival  in  town  stopped 
the  supply  of  liquors.     In  a  few  days  the  patient  became 


266  SCLEROSIS  OF  THE  SPINAL  CORD. 

rational  again,  and  I  was  then  requested  to  resume  my 
attendance.  When  I  saw  him  again,  he  frankly  apologised 
for  his  conduct,  and  expressed  his  fears  that  I  should  never 
forgive  him.  On  being  reassured  on  this  point,  his  mind 
became  more  easy,  and  he  appeared  to  improve  in  various 
ways  for  some  little  time.  On  December  20th,  however, 
he  had  several  epileptiform  fits,  with  total  loss  of  con- 
sciousness, and  great  muscular  rigidity.  These  fits  increased 
upon  him,  his  helplessness  became  greater  from  day  to 
day,  he  wandered  in  his  mind,  and  he  died  on  December 
30th,  having  for  some  time  previously  been  in  a  comatose 
condition. 

In  the  following  instance  symptoms  of  general  paralysis 
of  the  insane  became  developed  in  the  second  stage  of 
tabes : — 

Case  71. — In  March,  1882,  Dr.  Grasemann  asked  me  to 
see  a  piano-tuner,  aged  46,  single,  who  had  contracted 
syphilis  in  1870,  and  had  suffered  severely  from  it.  He 
had,  however,  apparently  recovered  from  that  disease,  when 
in  1875  he  began  to  complain  of  a  feeling  of  constriction 
round  the  chest,  which  was  thought  to  be  connected  with 
liver  and  stomach  derangement.  Some  time  afterwards 
lightning  pains  appeared  in  the  legs,  and  ataxy  of  gait 
gradually  became  developed.  The  patient's  mind  was  de- 
cidedly confused  when  I  first  examined  him.  There  was 
no  affection  of  the  cranial  nerves.  Ataxy  existed  in  both 
the  upper  and  lower  extremities.  The  legs  were  flabby 
and  thin  ;  there  were  constant  feelings  of  pins  and  needles, 
and,  occasionally  shooting  pains  in  the  limbs.  The  sexual 
power  was  lost  ;  the  bladder  in  a  state  of  atony,  with 
occasional  loss  of  control  over  the  retention  of  the  urine  ; 
and  constipation  was  habitual.  The  knee-jerk  was  absent 
in  both  sides.  Shortly  after  he  had  consulted  me,  the 
patient  was  recommended  by  his  friends  to  go  to  Aix-la- 
Chapelle  to  undergo  the  treatment  for  which  that  place  is 
so  well  known.     He  had  only  been  there  for  a  few  days. 


SYMPTOMS  OF  TABES  SPINALIS.  267 

wlien  severe  symptoms  of  mental  derangement  manifested 
themselves,  and  it  was  found  necessary  to  place  the  patient 
under  restraint.  I  have  since  understood  that  the  symp- 
toms of  general  paralysis  of  the  insane  became  developed 
shortly  afterwards. 

These  two  cases,  to  which  many  others  could  be  added, 
show  the  statement  current  in  the  older  treatises  on  tabes, 
viz.,  that  the  mental  faculties  remain  undisturbed  till  the 
end,  to  be  inconsistent  with  facts.  This  was  first  ascer- 
tained by  French  alienists,  such  as  Baillarger,  Magnan, 
Falret,  and  afterwards  more  especially  studied  by  E-ey^  and 
Rougier;^  and  several  forms  of  brain  affections  have  since 
been  distinguished. 

There  is  a  class  of  cases  in  whom  simple  impairment  of 
the  intellect  is  a  prominent  feature.  The  patient  is  no 
longer  able  to  attend  to  his  affairs  ;  there  are  no  delusions, 
but  imbecility,  which  gradually  becomes  deepened  :  he  has 
no  will  or  desire  of  any  kind,  appears  to  be  perfectly 
happy,  and  gives  no  trouble  at  all.  His  memory  seems  to 
be  a  blank,  and  if  he  still  speaks,  he  is  apt  to  stammer,  and 
does  not  finish  his  sentence.  The  facial  muscles  appear  in  a 
state  of  tremor.  Eventually  coma  supervenes,  and  after 
death  meningo-encephalitis  is  discovered,  together  with  the 
cord-lesion  characteristic  of  tabes. 

In  other  cases,  the  condition  which  has  just  been  described 
is  more  temporary,  and  apt  to  come  and  go.  There  is  then 
such  a  singular  jumble  of  cerebral  and  spinal  symptoms 
that  the  diagnosis  may  be  rendered  difficult,  more  especially 
at  first,  and  if  we  are  consulted  at  a  time  when  the  cerebral 
symptoms  predominate.  In  these  cases  we  find  another 
illustration  of  the  immense  diagnostic  importance  of  the 
loss  of  the  knee-jerk.     Whenever  Westphal's  symptom  is 

'  "ADnales  Medico-Psychologiques,"  5th  series,  vol.  xv.  Paris, 
Sept.,  1875. 

2  "Essai  sur  la  lypemanie  et  le  delire  de  persecution  chez  las 
tabetiques."     Paris,  1881. 


268  SCLEROSIS  OF  THE  SPINAL  CORD. 

found  to  be  present,  we  may  be  sure  that  there  is  an  affec- 
tion of  the  posterior  cokimns  of  the  lumbar  portion  of  the 
cord,  whether  ataxy  exist  or  not.  This  latter  point  is 
sometimes  difficult  to  decide,  as  in  some  forms  of  awkward- 
ness of  gait  the  symptoms  may  point  as  much  to  paresis  as 
to  ataxy. 

Westphal  finds  that,  out  of  a  hundred  patients  who  die 
of  general  paralysis  of  the  insane,  twenty  have  sclerosis  of 
the  posterior  columns  at  the  same  time.  Whether  the  symp- 
tom of  ataxy  is  present  in  these,  depends  upon  the  inten- 
sity of  the  disease  in  the  cord,  and  whether  there  is  much 
affection  of  the  posterior  roots.  Some  patients  die  of  the 
brain-disease  before  the  affection  of  the  cord  has  made  much 
progress.  Ataxy  of  gait  only  becomes  developed  when  a 
large  number  of  central  nerve-tubes  are  dead. 

Most  patients  who  suffer  from  tabes,  with  temporary, 
attacks  of  mental  derangement,  have  a  history  of  syphilis. 
Indeed  we  may  say  that  the  more  multiple  the  symptoms, 
the  more  probable  is  the  syphilitic  taint  in  a  patient,  for 
syphilis  has  the  tendency  to  produce  multiple  lesions  in 
different  areas  of  the  nervous  system.  The  characteristic 
feature  of  these  cases,  however  is,  that  the  spinal  symptoms 
are  constant  and  permanent,  while  the  cerebral  symptoms  are 
more  or  less  temporary  and  fleeting.  The  cause  of  this  is 
obvious.  Tabes  is,  even  in  the  beginning,  at  once  con- 
nected with  structural  lesions  in  the  cord ;  while  cerebral 
syphilis  creates  a  tendency  to  occasional  attacks  of  hyper- 
semia,  or  ischsemia,  which  cause  alarming  symptoms  at  the 
time  being,  but  are  apt  to  disappear  spontaneously  or  under 
the  influence  of  treatment. 

Magnan  has  related  a  case  in  which  the  patient,  aged 
forty-two,  came  from  a  healthy  stock  and  had  lived  tem- 
perately, until  in  1863  he  contracted  a  hard  chancre, 
which  was  quickly  followed  by  roseola  and  condylomata 
about  the  mouth.  This  yielded  to  specific  treatment, 
and  he    remained   well  until   1867,    when    he   was    sud- 


SYMPTOMS  OF  TABES    SPINALIS.  269 

denly    seized  with   lightning-pains,   to   which    were    soon 
added    other    symptoms    of    tabes,    viz.,    constriction    of 
the    chest,    vesical   crises,   sluggishness    of    the    bladder, 
plantar    anaesthesia,    Romberg's    symptom,    and    incoordi- 
nation  in   the    lower,     and    after    a    time,    in    the    upper 
extremities.     In  1880  the  intellect  became  impaired;  the 
patient  was  hypochondriacal,  and  had  delusions  of  persecu- 
tion.   He  said  that  his  body  had  lately  begun  to  smell  very 
badly,  and  his  companions  had  therefore    entered   into   a 
conspiracy  to  get  rid  of  him  ;  they  walked  at  night  in  a 
procession  round  his  bed,  brandishing  red-hot  pokers  ;  called 
him  abusive  names,  put  absinthe  into  his  cocoa,  &c.    A  simi- 
lar case  is  recorded  by  Falret.     It  was  that  of  a  man,  aged 
forty,  with  a  history  of  syphilis,  and  who  had  strabismus 
of  the  left    eye  in  1872.     Next  year  the  right   eye  was 
similarly  affected;  in  1874  he  had  a  stroke  of  hemiplegia. 
Lightning-pains  and  weakness  in  the  lower  extremities  then 
supervened,  and  his  mind  became  unhinged.     In   1879  he 
was  admitted  into  Bicetre,   with  a   number  of  symptoms 
of  tabes,  to  which  occasionally  maniacal  excitement,  with 
grandiose  delirium,   was    added.      He    imagined    that    he 
had  inherited  several  millions  of  money,  with  which  he  in- 
tended to   rebuild  Paris  ;  he  was  able  to  resuscitate  the 
dead  ;  was  President  of  the   Republic  and  King  of  Italy, 
had  invented  the  perpetuum  mobile,  and  a  means  of  pre- 
venting the  collision  of  steamboats.     He   was  also  subject 
to  visual  hallucinations  ;  on  one  occasion  he  saw  a  chapel 
full  of  sisters  of  charity  praying  at  the  altar,  with  priests 
conducting  the  service ;  when  suddenly  all  this  disappeared, 
and  an  old  woman  came  from  the  kitchen  and  blew  in  his 
face  with  a  pair  of  bellows. 

Rougier  has  given  an  interesting  theory  of  the  rationale 
of  the  development  of  some  forms  of  mental  disease  which 
are  observed  in  the  later  stages  of  tabes.  According  to 
him,  they  occur  chiefly  when  so  many  portions  of  the  ner- 
vous system  are  affected  that  morbid  impressions  perceived 


270  SCLEKOSIS  OF  THE  SPINAL  CORD. 

in  one  sphere  can  no  longer  be  corrected  by  another.  Thus 
a  tabid  patient  when  walking  on  deal  boards,  believes  that 
he  is  walking  on  wadding  ;  but,  provided  his  sight  be  good, 
he  has  only  to  look  to  his  feet  and  see  that  he  is  really 
walking  on  boards.  As  soon,  however,  as  blindness,  deaf- 
ness, and  anaesthesia  are  added  to  his  other  symptoms,  he 
may  not  only  readily  acquire  erroneous  impressions,  but 
also  be  convinced  of  their  reality. 

The  tabid  leads  a  fearful  life.  He  has  often  hardly 
words  enough  to  describe  the  tortures  which  he  constantly 
undergoes.  He  feels  as  if  the  flesh  were  torn  from  his 
bones,  as  if  his  inside  was  burnt  with  fire,  as  if  he  were 
being  impaled,  bitten  by  dogs  and  struck  by  daggers.^  Apart 
from  these  painful  sensations,  however,  he  may,  if  the  optic 
nerves  begin  to  suffer,  see  stars,  sparks,  flies  running,  or 
blackbirds  flying  about,  and  fancy  that  he  has  dust,  pieces 
of  coal  or  other  foreign  bodies  in  his  eyes.  When  deaf,  he 
perceives  tinkling  of  bells,  rolling  of  drums,  explosions  of 
gunpowder  and  singing  of  birds.  Taste  and  smell  may  be 
so  affected  that  all  kinds  of  food,  even  the  most  tasty  and 
delicate,  become  nauseous  and  horrible  ;  and  he  commonly 
believes  that  faeces  have  been  mixed  with  the  food.  As  for 
touch,  he  often  cannot  distinguish  between  the  bedclothes 
and  the  bedstead. 

In  consequence  of  there  being  hardly  any  but  painful 
and  unpleasant  sensations,  the  delirium,  where  it  occurs,  is 
of  a  depressed  character.  The  patient  imagines  himself 
persecuted ;  the  fearful  pains  from  which  he  suffers,  are 
attributed  to  imaginary  enemies  ;  he  says  that  he  is  tor- 
tured, poisoned,  insulted,  threatened,  magnetised,  choked 
by  horrible  smells;  that  his  life  is  being  attempted;  that 
his  feet  are  being  cut  off  ;  that  rotten  eggs,  sulphur,  phos- 
phorus, mineral  acids,  vermin-killer,  mud,  faeces,  arsenic, 
dynamite  and  verdigris  are  put  into  his  food ;  that  frogs 
and  guinea-pigs  are  placed  into  his  bed  ;  that  he  is  made 
^  Vide  description  of  "  Lightning  Pains,"  p.  146. 


SYMPTOMS  OF  TABES  SPINALIS.  271 

to  swallow  boiling  oil,  which  runs  all  the  way  through  his 
inside  and  out  again  at  the  anus  ;  that  faeces  are  put  into 
his  legs  ;  that  his  stomach  is  exploded  by  electricity,  etc. 
The  fog  or  mist,  due  to  optic  atrophy,  presently  becomes 
a  cloud,  then  a  blanket,  then  a  ghost,  and  finally  the  ghost 
speaks  to  him.  The  idea  of  persecution  will  easily  present 
itself  to  a  mind  unhinged  by  such  varieties  of  strange  sen- 
sations. 

Sometimes  there  are  regular  attacks  of  delirium  of  this 
kind  coinciding  with  attacks  of  hypera^sthesia,  and  the 
former  disappear  when  the  latter  subside.  There  is,  there- 
fore, always  a  material  base  of  suffering  and  distress 
in  the  sphere  of  the  sentient  or  sensorial  nerves  ;  but  the 
symptoms  from  which  the  patient  suffers  are  errone- 
ously interpreted  by  him.  This  condition  is  obviously  quite 
different  from  general  paralysis  of  the  insane.  There  is  no 
affection  of  language  ;  the  patient  expresses  himself  with 
the  greatest  volubility,  and  has  not  the  slightest  difficulty 
in  finding  his  words  or  finishing  a  sentence  ;  there  is  no 
tremor  in  the  facial  muscles  ;  the  memory  is  good  ;  and 
there  are  perfectly  lucid  intervals. 

At  this  period  of  the  disease,  the  patients  become  very 
vulnerable,  and  lose  their  power  of  resistance  to  morbid 
influences.  The  nervous  system  has  now  become  incurably 
altered,  and  the  trophic  influence  of  the  spinal  cord  is 
extremely  reduced.  They,  therefore,  easily  die  of  inter- 
current affections,  such  as  bronchitis,  typhoid  fever,  and 
sometimes  of  simple  collapse,  which  may  be  attended  with 
convulsions. 

Case  72. — In  March,  1865,  I  was  consulted  by  a  retired 
officer,  aged  forty-five,  single,  who  had  "  lived  very  hard." 
He  had  had  gonorrhoea,  syphilis,  and  delirium  tremens. 
He  now  suffered  from  what  he  called  "  sciatica "  in  the 
right  leg,  but  which  on  closer  examination  turned  out  to  be 
lightning  pains.  He  had  great  difficulty  in  walking,  with 
numbness  in  the  legs,  weakness  of  the  bladder,  bowels  and 


272  SCLEROSIS  OP  THE  SPINAL  CORD. 

sexual  organs,  and  numbness  in  the  hands,  more  especially 
in  the  right,  which  also  showed  signs  of  ataxy.  A  month 
after  I  had  first  seen  him,  he  had  one  of  his  habitual 
drinking  bouts,  which  led  very  nearly  to  another  attack 
of  delirium.  He  heard  voices,  saw  visions,  and  was 
"  frightened  to  death,"  although  perfectly  conscious  and 
able  to  converse.  This  yielded  to  morphia,  but  the  patient 
now  lost  ground  rapidly.  In  June  of  the  same  year,  he 
was  taken  to  Wildbad,  in  Germany,  and  died  there,  quite 
suddenly,  in  a  severe  fit  of  convulsions. 

Diseases  of  the  heart  and  sclerotic  or  sclero- athero- 
matous endo-aortitis,  occur  not  unfrequently  towards  the 
end  of  the  malady  ;  and  Berger  and  Rosenbach^  have 
seen  seven  cases  of  coincidence  of  tabes  with  aortic  in- 
sufficiency. These  authors  consider  that  there  is  a  relation- 
ship between  the  two  conditions,  while  Vulpian  leaves  this 
an  open  question,  and  seems  rather  inclined  to  think  that 
it  is  a  mere  coincidence.  Letulle  and  G-rasset  have  col- 
lected a  number  of  cases,  showing  that  all  kinds  of  heart 
disease  may  occur  in  the  terminal  stage  of  tabes,  and  that 
they  do  not  in  general  cause  much  trouble  at  first,  but 
become  pronounced  in  their  effects  later  on,  and  occasionally 
lead  to  a  fatal  result  by  syncope. 

Teissier  ^  who  has  quite  recently  investigated  the  same 
subject,  is  led  to  the  conclusion  that  tabes  and  atheromatous 
degeneration  of  the  aortic  valves  are  generally  found  to- 
gether, and  considers  them  identical  in  a  pathological 
point  of  view.  There  is  endo-arteritis  of  the  arterioles, 
and  sclero-fibrous  degeneration  of  the  blood-vessels  is 
the  result.  In  most  cases  this  affection  of  the  aortic 
valves  may  not  be  recognised  in  the  living  ;  while  the 
autopsy  shows  small  perforations  of  the  aortic  valves 
which  have  nothing  to  do  with  senile  decay,  as  they  are 
found  at  such    an  early   age   as  twenty-five.     The  same 

1  "  Berliner  klinische  Wockensclirift,"  p.  402,  1879. 

2  "  Lyon  Medical,"  1884,  No.  6. 


SYMPTOMS  OF  TABES  SPINALIS.  273 

morbid  changes  are  also  discovered  in  multiple  sclerosis, 
epilepsy,  paralysis  agitans,  etc. 

As  patients  linger  on  the  road  to  dissolution,  paralysis 
invades  first  one  leg  and  then  the  other.  Permanent  con- 
tractions of  the  affected  limbs  are  then  gradually  estab- 
lished, showing  that  the  disease  has  crept  on  to  the  lateral 
columns  of  the  cord  ;  or  there  is  great  muscular  wasting, 
owing  to  sclerosis  of  the  anterior  horns  of  the  central 
grey  matter.  Sometimes  a  kind  of  sub-acute  poliomyelitis 
is  observed,  which  entails  speedy  loss  of  farado-muscular 
contractility,  and  destruction  of  the  muscular  substance. 
Sensibility  is  now  almost  entirely  in  abeyance,  but  may  still 
be  roused  for  a  time  by  energetic  faradisation  of  the  skin. 
Bedsores  form  at  the  sacrum  and  heels  ;  the  paralysed 
bladder  becomes  affected  by  ulceration  and  gangrene  ;  in- 
flammation may  then  spread  to  the  pelvis  of  the  kidneys, 
and  the  patient  is  carried  off  by  pyelo-nephritis.  Phthisis, 
heart  and  aortic  disease,  obstruction  of  the  bowels,  and  acute 
meningitis,  may  all  in  their  turn  put  an  end  to  the  suffer- 
ings of  the  patient,  who  is  at  last  glad  to  die  and  be  re- 
leased from  a  life  which  is  in  truth  worse  than  death. 
Only  those  who  are  highly  gifted  with  intellectual  powers, 
and  have  preserved  these  undecayed  to  the  end,  may  still 
look  upon  their  own  condition  at  this  stage  with  a  kind  of 
grim  humour. 

Thus  the  German  poet  Heine,  who  died  of  tabes  in  Paris 
in  1856,  after  the  most  frightful  tortures,  says  in  his  intro- 
duction to  that  wonderful  work,  "  Eomanzero,"  written  by 
a  hand  which  was  nearly  paralysed,  while  ptosis  prevented 
him  from  seeing  what  he  had  written: — 

"  Do  I  really  exist  ?  My  body  is  so  shrunken  that  I  am 
hardly  anything  but  a  voice  ;  in  my  mattress-grave  in  the 
noisy  city,  I  hear  early  and  late  nothing  but  the  rolling  of 
vehicles,  hammering,  quarrelling,  and  piano-strumming.  A 
grave  without  repose,  death  without  the  privileges  of  the 
dead,  who  at  least  need  not  spend  any  money,  nor  write 

T 


274  SCLEROSIS  OF  THE  SPINAL  CORD. 

letters  or  books — that  is  indeed  a  pitiful  condition.  Long 
ago  the  measure  has  been  taken  for  my  coffin  and  my 
obituary ;  but  I  die  so  slowly  that  the  process  is  tedious 
for  myself  as  well  as  my  friends.  What  avails  me  that 
enthusiastic  youths  and  maidens  crown  my  marble  bust 
with  laurel,  when  the  withered  hands  of  an  aged  hag 
are  putting  blisters  behind  my  ears  ?  What  avails  me 
the  incense  of  the  roses  of  Shiraz,  when  in  the  wearisome 
loneliness  of  my  sick  room  I  get  no  perfume  but  the  smell 
of  hot  towels  ?  But  patience  ;  everything  has  an  end  ! 
You  will  one  day  find  the  booth  closed  where  the  puppet- 
show  of  my  humour  has  so  often  delighted  you." 


275 


CHAPTER    YII. 

THE  DIAGNOSIS  OF  TABES  SPINALIS. 

The  symptoms  of  this  disease  have  been  so  fully  described 
in  the  preceding  chapter  that  our  remarks  on  the  differen- 
tial diagnosis  of  tabes  from  other  diseases  may  be  brief. 
More  especially  the  second  or  ataxic  stage  presents  such 
striking  features,  that  a  competent  observer  will  often 
recognise  it  at  a  glance  ;  while  on  the  other  hand,  in  the 
initial,  and  again  in  the  terminal  stage,  of  the  malady,  it 
will  occasionally  require  all  the  diagnostic  resources  at  our 
disposal  for  recognising  the  true  nature  of  the  disease. 

1st.  The  initial  or pre-ataxic  stage  often  resembles  in  some 
points  that  form  of  functional  derangement  of  the  spinal 
cord  which  is  known  as  spinal  debility  or  neurasthenia.  In 
both  affections  there  may  be  a  general  feeling  of  lassitude 
and  want  of  energy^  particularly  in  the  motor  sphere  ;  the 
patient  has  a  difficulty  in  walking  or  standing  for  any 
length  of  time,  and  is  easily  knocked  up  after  trifling  efforts. 
The  neurasthenic  frequently  complains  of  an  aching  pain  in 
the  legs  after  exertion  ;  but  this  is  not  nearly  so  violent  as 
the  lightning-pains  of  tabes,  and  more  apt  to  be  continuous 
than  intermittent. 

In  neurasthenia  the  back  is  often  in  a  state  of  hyper- 
aesthesia ;  pressure  on,  and  percussion  of,  some  of  the 
spinous  processes  of  the  vertebrae  cause  intense  pain,  and 
may  give  rise  to  exaggerated  reflexes  in  the  neighbouring 
spinal  muscles.     Schuster  ^  states  that  while  there  may  be, 

'  "Diagnostik  der  Eiickenmarkskrankheiten,"  2te  Auflage,  p.  73. 
Berlin,  1884. 

T  2 


276  SCLEROSIS  OF  THE  SPINAL  CORD. 

in  the  first  stage  of  tabes,  short  shoots  of  pain  in  the  back, 
there  is   no  tenderness  on  pressure  ;  and  that  tabes  may 
thereby  be  distinguished  from  neurasthenia,  where  there  is 
much  pain  in  the  neck,  back  and   shoulders,  and  which  is 
increased  by  pressure.     There  are,  however,   exceptions  to 
this  rule  ;  and  the  case  related  on  p.  200  shows  that  there 
may  be  a  high  degree  of  hypereesthesia  in  the  back,  with 
tenderness  on  pressure,  in  the  first  stage  of  tabes.     In  both 
diseases  which  we  are  now  considering,  there  may  be  a  feel- 
ing of  coldness  and  numbness  in  the  hands  and  feet ;    the 
sexual  power  may  be  diminished  ;  nocturnal  emissions  may 
be   frequent ;    sexual  indulgence,  even  to  a  very  moderate 
extent,  may  lead  to  increased  debility  ;    and  a  degree  of 
ansemia  may  be  present.     Finally,  there    may  be  in  both 
intense  depression  of    spirits,  and    fear  of  an   impending 
severe  illness.     On  the  other  hand,  however,  we  find  that 
there  are  scarcely  any  objective  symptoms  in  neurasthenia; 
the  various  tests  which  we  use  in  the  diagnosis   of  tabes 
are  gone  through  with  the  most  satisfactory  results  ;  there 
is  no  loss  or  exaggeration  of  the  patellar  reflexes  ;  no  in- 
continence of  the  urine  or  faeces  ;  no  sign  of  optic  atrophy  ; 
no  crises  of  any  sort ;  the  pulse  is  rarely  accelerated.     The 
pupils  may  be  habitually  large,  but  respond  perfectly  to 
light.     The  absence  of  all  objective  symptoms  pointing  to 
tabes  is  therefore  in  generfe,l  sufficient  for  a  diagnosis  ;  and 
it  is  a  mistake  to  suppose  that  neurasthenia  ever  merges 
into  tabes,  as  has  been  frequently  asserted.     The  two  con- 
ditions are  essentially  distinct  from  the  beginning,  and  re- 
main so  during  their  entire  further  progress,  whatever  may 
be  their  duration. 

With  hysteria,  as  generally  understood,  tabes  has  no 
chance  of  being  confounded,  but  that  particular  affection 
which  is  so  common  in  young  women,  and  known  as 
irritable  spine,  has  certainly  some  features  in  common  with 
tabes.  Irritable  spine  is  no  doubt  frequently  found  in  the 
selfish  victims  of  hysteria ;  but  it  also  occurs  in  the  higher 


THE  DIAGNOSIS  OF  TABES  SPINALIS.  277 

class  of  neurotics,  who  may  be  full  of  energy,  and  only  too 
eager  to  get  well  and  take  an  active  share  in  the  toils  and 
pleasures  of  life.  The  principal  symptom  is  backache, 
chiefly  between  the  shoulders  and  the  nape  of  the  neck, 
combined  with  extreme  hypersesthesia,  so  that  the  least 
touch  is  unbearable ;  and  as  the  pain  and  hypersesthesia  are 
apt  to  be  increased  by  the  most  trifling  exertion,  the  patient 
is  necessarily  reduced  to  the  condition  of  an  invalid.  In 
addition  to  this  there  is  a  great  degree  of  motor  debility, 
just  as  in  neurasthenia  and  some  forms  of  the  initial  stage 
of  tabes.  Other  symptoms  vary  according  to  the  portion 
of  the  spine  which  is  chiefly  affected.  Where  the  cervical 
part  suffers  more  particularly,  there  is  in  addition  to  the 
backache,  vertigo,  pain  in  the  head,  more  especially  the 
back  of  it,  sleeplessness,  hiccough,  retching,  vomiting, 
palpitations  of  the  heart,  and  great  diflaculty  in  using  the 
arms  and  hands.  The  patient  is  unable  to  dress  herself 
without  assistance,  cannot  play  the  piano,  embroider,  or 
write  letters.  If  the  dorsal  portion  of  the  spine  is  more 
affected,  there  is  gastralgia,  nausea,  vomiting,  distension  of 
the  abdomen,  and  asthma ;  and  where  the  lumbar  part 
suffers,  shooting  pains  through  the  legs,  impossibility 
to  walk,  obstinate  coldness  of  the  feet,  difficulties  in 
urination,  defsecation  and  menstruation  are  the  chief 
symptoms.  The  patients  are  therefore  often  exceedingly 
ill,  yet  there  are  few  objective  signs  such  as  we  meet  with 
in  the  first  stage  of  tabes  ;  and  the  tendon  reflexes  are 
never  absent,  but  almost  invariably  greatly  exaggerated. 
This  latter  sign  speaks  decisively  against  tabes. 

Rheumatism,  gout,  and  i^heumatic  gout,  are  frequently 
believed  to  be  the  cause  of  the  lightning-pains  of  tabes. 
An  eminent  member  of  the  profession  in  London,  who  is 
well  advanced  in  the  second  stage  of  tabes,  always  speaks 
of  his  complaint  as  "gout."  Attacks  of  lightning-pains  are 
set  down  as  paroxysms  of  "  gout "  induced  by  incautiously 
partaking  of  his  excellent  Burgundy  and  port  wine  ;  and 


278  SCLEROSIS  OF  THE  SPINAL  CORD. 

the  habitual  difficulty  in  walking  is  ascribed  to  gouty 
deposits  in  his  hips,  knees  and  ankles.  Most  lay-patients 
describe  their  lightning-pains  as  "rheumatic,"  and  con- 
sider that  their  symptoms  are  owing  to  chronic  rheumatism. 
Tabes  can  never  be  confounded  with  rheumatic  fever ;  but 
some  forms  of  subacute  and  chronic  rheumatism  may 
occasionally  resemble  it.  The  rheumatic  pain,  however,  is 
essentially  different  from  the  lightning  pain.  It  is  much 
more  constant,  not  so  severe,  and  more  apt  to  be  increased 
by  movement.  The  regular  attack  of  gout,  again,  cannot 
be  confounded  with  tabes,  as  in  the  latter  there  is  no  acute 
inflammation  of  the  small  joints  ;  but  some  forms  of 
irregular  gout  may  occasionally  lead  the  unwary  astray. 
There  may  be  in  that  affection  acute  gastralgia,  resembling 
a  gastric  crisis,  with  intense  spasmodic  pain  in  the  epigas- 
trium, and  bilious  vomiting,  and  some  degree  of  collapse. 
There  may  also  be  a  kind  of  intestinal  colic,  resembling 
the  intestinal  crisis  (p.  210) ;  a  feeling  of  constriction  of 
the  chest,  praecordial  anxiety,  and  asthmatic  attacks 
not  unlike  the  laryngeal  crises  (p.  186).  The  history  of 
the  case,  the  presence  of  gouty  concretions,  and  the 
absence  of  Westphal's  symptom,  will,  however,  even  in 
apparently  anomalous  cases,  be  sufficient  to  establish  a 
correct  diagnosis. 

The  arthropathy  of  tabes  cannot  well  be  confounded 
with  rheumatic  gout.  We  have  seen  (p.  216)  that  in  the 
former  there  is  a  sudden  swelling  in  a  joint,  with  effusion 
of  synovia,  and  unaccompanied  by  pain,  redness,  or  heat ; 
the  principal  seat  of  the  affection  being  the  knee  or 
shoulder-joint.  In  rheumatic  gout  on  the  other  hand,  the 
evolution  of  the  arthropathy  is  slow ;  there  is  only  a  small 
quantity  of  liquid  effused,  and  the  principal  seat  of  the 
affection  is  in  the  joints  of  the  fingers  and  toes,  and  the 
hip-joint. 

Patients  suffering  from  diabetes,  on  the  other  hand,  may 
present  numerous   symptoms   resembling  those  which  are 


THE  DIAGNOSIS  OP  TABES  SPINALIS.  279 

observed  in  the  initial  period  of  tabes.  The  earliest,  most 
frequent,  and,  diagnostically  speaking,  most  important 
symptom  in  the  sphere  of  the  nervous  system  which  occurs 
in  diabetes,  is  one  which  we  also  know  as  a  symptom 
of  tabes  (p.  205)  and  spinal  neurasthenia,  viz.,  a  sensa- 
tion of  fatigue,  lassitude,  and  utter  want  of  muscular 
energy.  This  does  not  depend  on  the  emaciation  of  the 
muscles,  which  is  one  of  the  later  symptoms  of  the  malady  ; 
but  comes  on,  without  any  apparent  cause,  either  in  the 
lower  extremities  or  in  the  loins,  and  may  be  severe 
enough  to  raise  a  suspicion  of  spinal  disease.  There  is 
difficulty  in  walking ;  the  movements  are  slow,  awkward, 
and  without  vigour.  This  lack  of  power  may  come  on 
quite  suddenly,  for  instance  after  a  slight  accident,  and  is 
possibly  owing  to  defective  muscular  nutrition  from  the 
blood  being  saccharine. 

Various  forms  of  paralysis  are  also  observed  in  diabetes, 
which  may  be  local,  partial,  and  incomplete  ;  or  there  may 
be  regular  hemiplegia.  The  latter  may  come  on  suddenly, 
with  apoplexy,  and  may  get  well  in  a  few  days,  just  as 
occurs  in  tabes  (p.  194),  and  there  may  be  a  repetition  of 
these  symptoms  at  some  subsequent  period.  In  other  cases 
the  apoplexy  proves  fatal,  or  there  may  be  simple  loss  of 
consciousness  without  subsequent  paralysis,  or  a  bad 
attack  of  vertigo.  Again,  paralysis  may  come  on  without 
being  preceded  by  apoplexy ;  and  hemiplegia  of  one  side 
may  be  combined  with  monoplegia  of  the  other.  Mono- 
plegia is  indeed  so  frequent  in  the  course  of  diabetes  that 
it  is  always  incumbent  on  the  practitioner  to  examine  the 
urine  for  sugar  in  these  cases.  Palsies  of  this  kind  may 
be  confined  to  a  limb,  or  part  of  a  limb ;  to  a  single  muscle, 
or  a  small  group  of  muscles  in  the  face  ;  and  they  affect 
frequently  the  tongue  and  the  muscles  moving  the  eye- 
ball. They  may  be  quite  transitory,  indeed  last  for  a  few 
hours  only,  and  arc  often  incomplete. 

Difficulty  in   speaking   may   be  either   of   the   aphasic 


280  SCLEROSIS  OF  THE  SPINAL  CORD. 

or  the  anartliric  kind,  or  be  simply  owing  to  general 
debility  combined  with  dryness  of  the  tongue.  Some- 
times, there  is  a  more  or  less  complete  loss  of  the  memory 
for  words.  A  temporary  kind  of  aphonia  is  probably 
owing  to  transitory  paralysis  of  the  muscles  of  the  larynx. 
There  are  not  as  yet  any  very  conclusive  observations  on 
palsies  of  the  muscles  of  the  eye,  although  Kiwatkowski 
has  recorded  a  case  of  paralysis  of  the  fourth  nerve  in  a 
diabetic  patient,  and  the  rectus  externus  has  been  found 
paralysed  under  similar  conditions. 

Another  interesting  symptom  in  the  motor  sphere  in 
diabetes  is  a  tottering  gait,  especially  in  the  dark.  This 
may  be  combined  with  ''pins  and  needles"  in  the  lower 
extremities,  just  as  in  tabes.  Indeed,  one  cannot  help  being 
struck  by  the  close  similarity  of  many  of  these  symptoms 
to  those  of  locomotor  ataxy. 

A  symptom,  however,  which  is  frequent  in  diabetes,  and 
absent  in  tabes,  is  cramp  in  the  legs,  which  occurs  chiefly 
at  night,  and  leads  to  sleeplessness.  The  latter,  however, 
may  also  occur  in  diabetes  simply  from  the  nutrition  of  the 
brain  being  impaired  through  the  saccharine  blood  ,•  indeed, 
if  insomnia  appears  without  any  apparent  cause,  diabetes 
may  be  suspected.  In  tabes,  insomnia  occurs  generally 
only  during  attacks  of  lightning-pains  or  crises  of  any 
description. 

On  the  other  hand,  we  find  in  diabetes  symptoms  which 
again  closely  resemble  those  of  tabes,  viz.  : — In  the  sphere 
of  sensibility  local  areas  of  anaesthesia  and  analgesia,  so 
that  hairs  may  be  pulled  out  without  causing  any  pain  to  the 
patient.  More  frequently  there  are  complaints  of  tingling, 
tightness,  cold,  heat,  and  numbness,  especially  in  one  or 
both  lower  extremities  or  in  the  sexual  organs.  Like  the 
tabid  patient,  the  diabetic  is  exceedingly  sensitive  to 
cold.  Tactile  sensibility  may  vanish,  so  that  the  patient 
is  unable  to  hold  a  pin  between  his  fingers  without  look- 
ing at  it.      Some  patients  lose  the  proper  sensation  of  the 


THE  DIAGNOSIS  OF  TABES  SPINALIS.  281 

ground  on  which  they  are  walking.  Pain  in  the  joints,  the 
loins,  the  haunches,  and  the  back  is  common ;  and  it  seems 
particularly  to  invade  the  neck,  where  it  is  felt  as  a  burn 
or  the  bite  of  a  dog,  and  is  combined  with  stiffness  of  the 
muscles.  This  rigidity  extends  occasionally  from  the  back 
of  the  head  down  to  the  sacrum.  There  may  also  be 
headache,  pressure  on  the  top  of  the  head,  and  various 
forms  of  neuralgia,  more  especially  symmetrical  and 
obstinate  sciatica.  Lightning-pains,  similar  to  those  of 
tabes,  have  likewise  been  observed,  and  may,  if  combined 
with  difficulty  in  standing,  plantar  anesthesia,  and  areas  of 
hypersesthesia,  lead  a  hasty  observer  to  the  diagnosis  of 
tabes. 

Sexual  desire  is  generally  in  abeyance.  In  men  there  is 
frigidity  and  impotency ;  in  women,  actual  repugnance  to 
connection.  Certain  neuroses,  such  as  asthma,  angina 
pectoris,  etc.,  may  resemble  the  laryngeal  crises  which 
are  known  to  occur  in  tabes.  Deafness  is  more  frequent 
in  the  diabetic  than  in  other  persons,  and  seems  sometimes 
purely  nervous,  while  in  other  cases  it  is  owing  to  lesions 
of  the  middle  ear.  Anorexia  and  perversion  of  the  sense 
of  smell  have  also  been  observed. 

Certain  peculiar  nutritive  disturbaDces  which  we  have 
seen  to  occur  in  tabes  (p.  218)  may  also  occur  in  diabetes, 
more  especially  perforating  ulcer  of  the  foot,  bed-sores, 
localised  sweating,  and  muscular  atrophy. 

An  additional  element  of  uncertainty  in  these  cases  is 
that  sugar  may  be  found  in  the  urine  of  the  tabid  (p.  263); 
while  on  the  other  hand  Pavy  has  shown  that  the  palsies 
and  other  nervous  symptoms  of  diabetes  may  occur  some 
time  before  the  diabetes  appears,  or  just  when,  in  conse- 
quence of  treatment  or  otherwise,  the  sugar  disappears  from 
the  urine,  or  after  it  has  been  completely  absent  from  it 
for  several  months  consecutively.  The  other  symptoms  of 
diabetes,  such  as  hunger,  thirst,  polyuria,  emaciation,  etc., 
may  under   such  circumstances   not  be  very  marked,  and 


282  SCLEROSIS  OF  THE  SPINAL  CORD. 

where  the  nervous  symptoms  which  have  been  described 
are  very  prominent,  as  is  chiefly  the  case  in  those  having 
inherited  the  neurotic  constitution,  diabetes  and  tabes  may 
indeed  resemble  one  another  in  the  closest  possible  manner ; 
so  closely  indeed  that  occasionally  a  decision  would  be 
actually  impossible  without  our  sheet-anchor  for  the  diag- 
nosis of  tabes,  viz.,  Westphal's  and  Argyll-Robertson's 
symptoms,  which  never  occur  in  diabetes,  and  therefore 
are  of  the  utmost  value  when  we  are  called  upon  to  decide 
the  nature  of  such  excessively  obscure  and  doubtful  cases. 

Amblyopia  and  amaurosis  also  occur  in  the  course  of 
diabetes,  adding  another  symptom  common  to  both  dis- 
eases. Here,  however,  the  ophthalmoscope  steps  in,  show- 
ing that  in  the  amblyopia  of  the  earlier  stages  of  diabetes, 
the  fundus  of  the  eye  is  normal,  or  that  there  is  at  most  a 
slight  congestion  of  the  optic  disc.  The  amblyopia  of 
diabetes  is  indeed  owing  to  paresis  of  accommodation, 
which  is  no  doubt  caused  by  the  saccharine  state  of  the 
blood.  It  may,  therefore,  be  compared  with  ursemic 
amaurosis,  where  occasionally  likewise  no  ophthalmo- 
scopic changes  are  observable.  In  general  the  two  eyes 
are  unequally  affected;  all  objects  appear  to  the  patient  in 
a  kind  of  yellowish  haze ;  and  this  is  worse  after  meals.  A 
severer  form  of  true  amaurosis  may  come  on  towards  the 
end.  This  is  owing  to  glycosuric  retinitis,  and  resembles 
albuminuric  retinitis,  and  the  changes  in  the  retina  seen  in 
pernicious  ansemia.  Haemorrhage  occurs  almost  invariably, 
and  this  may  lead  to  secondary  parenchymatous  retinitis. 
Simple  atrophy  of  the  optic  nerve  may,  however,  likewise 
exist,  and  thus  render  the  diagnosis  even  more  doubtful. 
The  commonest  cause  of  defect  of  sight  in  diabetes,  how- 
ever, is  cataract,  which  does  not  occur  in  tabes,  and  there- 
fore may  be  utilised  for  diagnostic  purposes. 

The  patient  whose  case  (No.  55)  is  described  on  p.  195, 
and  who  suffered  from  tabes  combined  with  glycosuria 
had  been   pronounced   to   suffer    from    diabetes  by  a  dis- 


THE  DIAGNOSIS  OF  TABES   SPINALIS.  283 

tinguishecl  physician,  and  on  this  account  been  sent  to 
Neuenahr— a  spa  utterly  unsuited  for  his  condition.  This 
shows  the  practical  importance  of  the  diagnostic  tests  be- 
tween tabes  and  diabetes  which  I  have  mentioned. 

Amblyopia  and  amaurosis  from  optic  atrophy  in  tabes 
may  be  distinguished  from  impairment  or  loss  of  vision 
through  optic  neuritis,  such  as  we  see  it  in  tumour  of  the 
brain,  meningitis,  abscess,  and  softening  of  the  brain  from 
embolism  or  thrombosis,  etc.,  chiefly  by  the  evidence  ob- 
tained with  the  aid  of  the  ophthalmoscope.  The  ophthal- 
moscopic signs  of  optic  atrophy  (p.  172)  are  chiefly  pallor 
and  excavation  of  the  disc,  the  edge  of  which  appears 
extremely  sharp  ;  while  in  optic  neuritis,  on  the  contrary, 
we  have  increased  redness,  swelling  and  cloudiness  of  the 
disc,  the  edge  of  which  is  blurred  and  imperceptible,  the 
centre  being  darker  than  the  periphery,  while  the  veins 
are  enlarged  and  the  arteries  narrowed.  The  other  clinical 
symptoms  of  the  two  affections  do  not  present  such  a 
striking  contrast.  It  is  true  that  in  optic  atrophy  one  eye 
always  commences  to  fail  before  the  other,  and  that 
optic  neuritis  is  often  at  once  bilateral ;  yet  the  affection 
may  also  commence  in  one  eye  in  optic  neuritis.  Vision 
becomes  impaired  or  lost  in  both  diseases,  and  in  both 
there  is  limitation  of  the  visual  field,  and  achromatopsy, 
red  and  green  being  lost  before  blue  and  yellow.  In 
general,  however,  optic  neuritis  is  much  more  rapidly 
destructive  of  sight  than  atrophy,  for  blindness  may  occur 
in  the  former  within  two  or  three  days,  while  it  will  take 
at  least  as  many  months  or  years  before  sight  completely 
fails  from  optic  atrophy.  Blindness,  however,  never  comes 
on  instantaneously  from  optic  neuritis,  as  it  will  do  from 
embolism  of  the  central  artery  of  the  retina.  From  this  it 
will  be  seen  that  the  ophthalmoscopic  signs  are  by  far  the 
most  valuable.  Charcot  relates  a  case  where  it  was 
difficult  to  determine  whether  a  patient  was  suffering  from 
tabes  or  from  tumour  of  the  occipital  lobes  of  the  brain, 


284  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  where  Galezowski  was  enabled  to  make  a  correct 
diagnosis  by  means  of  the  ophthalmic  mirror.  It  is  right 
to  say  that  this  case  occurred  at  a  time  when  Westphal's 
symptom  was  not  yet  habitually  utilised  in  France,  as 
otherwise  no  such  difficulty  could  have  arisen  ;  for  in 
tumour  of  the  brain,  wherever  situated,  the  tendon  reflexes 
are  invariably  exaggerated,  while  in  tabes  they  are  lost. 

Lightning-pains  are  often  confounded  with  neuralgia^ 
more  especially  when  they  affect  chiefly  or  exclusively  the 
sphere  of  a  certain  nerve  or  nerve-branch.  The  pain  in 
both  affections  may  be  equally  severe,  and  present  the  same 
characters  as  regards  intermittence,  etc.  A  search  for 
other  symptoms  of  tabes,  however,  will  in  cases  of  neu- 
ralgia be  generally  unsuccessful,  while  in  tabes  it  will 
result  in  the  discovery  of  the  loss  of  the  knee-jerk,  Argyll- 
Robertson's  symptom,  etc. 

Gastralgia,  on  which  Clifford  Allbutt^  has  recently  dis- 
coursed so  eloquently  and  impetuously,  may  at  first  sight 
closely  resemble  the  gastric  crisis.  The  pain  is  equally 
intense,  and  the  attack  liable  to  come  on  suddenly  and 
without  much  warning.  Yet  gastralgia  occurs  chiefly  in 
young  women,  and  is  often  preceded  and  followed  by  other 
symptoms  of  stomach-derangement  ;  while  the  gastric 
crisis  occurs  chiefly  in  men  in  the  prime  of  life,  is  accom- 
panied by  other  symptoms  of  tabes,  and  rarely  by  con- 
tinuous derangement  of  digestion. 

Enteralgia,  as  described  by  the  same  observer,  may  occur 
as  a  pure  neurosis  or  as  a  symptom  of  gout  ;  and  it  may 
closely  resemble  the  intestinal  crisis  of  tabes.  The  severity 
of  the  pain  is  very  great  in  both  conditions,  for  AJlbutt's 
patients  also  complain  of  "  stabs  and  racking  of  a  knife," 
and  of  such  frightful  agony  that  death  seems  preferable  to 
the  torture  they  endure.  The  pain  of  enteralgia  is  chiefly 
seated  in  the  right  iliac  fossa  and  the  umbilicus.  Neu- 
ralgia of  the  liver,  kidney,  rectum,  and  bladder  appears 
1  "  On  Visceral  Neuroses,"  p.  30.     London,  1884. 


THE  DIAGNOSIS  OF  TABES  SPINALIS.  285 

to  fall  into  the  same  category  ;  and  so  would  neurotic 
attacks  of  diarrhoea.  The  latter  occur  from  nervous  causes, 
and  are  generally  associated  with  other  neuroses,  such  as 
migraine,  cardio-vascular  instability,  etc.  In  all  these 
affections  the  presence  or  absence  of  the  knee-jerk  will,  in 
the  last  resort,  be  of  decisive  diagnostic  importance. 

In  those  cases  of  tabes  where  gastric  crises  form  a  pro- 
minent symptom,  certain  diseases  of  the  stomach  have  until 
quite  recently  been  confounded  with  the  cord-disease  ;  and 
the  diagnosis  of  ulcer  or  cancer  of  the  stomach,  or  of  biliary 
and  renal  calculi,  has  been  freely  made.  Haematemesis 
more  especially  has  until  lately  been  almost  invariably  re- 
ferred to  ulcer  or  cancer  of  the  stomach,  but  we  know  now 
that  it  is  a  symptom  which  is  apt  to  supervene  towards  the 
■end  of  the  gastric  crisis,  and  simply  through  excessive  ner- 
vous irritation  without  actual  disease  of  the  stomach.  Yet 
there  are  many  points  which  will  help  us  towards  a  proper 
diagnosis  of  the  case.  We  should  remember  that  ulcer  of  the 
stomach  is  much  more  frequent  in  women  than  in  men, 
while  in  tabes  the  reverse  is  the  casej  that  it  is  more  com- 
mon in  advanced  age,  while  tabes  is  a  disease  of  the  prime 
of  life  ;  that  the  pain  of  ulcer  always  comes  on  after,  and 
in  consequence  of,  taking  food,  while  the  gastric  crisis  of 
tabes  is  quite  uninfluenced  by  this  ;  that  in  ulcer  the  pain  is 
generally  localised  in  the  epigastrium  or  left  hypochondrium, 
or  in  a  certain  portion  of  the  back,  and  there  is  tenderness 
on  pressure,  while  in  the  gastric  crisis  the  pain  shoots  over 
a  considerable  area,  and  is  not  materially  increased,  but 
often  rather  relieved  by  pressure.  Vomiting  in  ulcer  is  not 
common,  and  almost  invariably  ceases  after  the  food  ingested 
has  been  brought  up,  while  in  the  gastric  crisis  it  is 
incessant,  and  continues  long  after  the  contents  of  the 
stomach  and  duodenum  have  been  voided.  Ulcer  is  dis- 
tinguished by  its  chronic  course,  and  the  gastric  crisis 
by  an  extremely  acute  occurrence.  Finally,  in  ulcer  the 
patellar  reflex  is  present,  and  in  tabes  it  is  absent. 


286  SCLEROSIS  OP  THE  SPINAL  CORD. 

Perforation  of  the  stomach  and  bowel,  occurring  from  ulcer- 
ation, resembles  in  some  respects  the  gastric  crisis :  there 
is  intense  pain  in  the  abdomen,  and  vomiting,  and  it  maj 
occur  where  there  has  been  only  little  complaint  of  previous 
ill-health.  But  in  the  gastric  crisis  the  patient  is  restless 
and  writhes  about  in  bed,  while  in  perforation  he  keeps 
perfectly  still  in  the  recumbent  position,  and  dreads  the 
slightest  movement  ;  the  symptoms  of  peritonitis  soon 
become  developed,  and  are  then  nnmistakeable.  The  pas- 
sage of  biliary  and  renal  calculi  is  sometimes  ushered  in  by 
symptoms  exactly  resembling  the  gastric  crisis  ;  and  in 
such  cases  we  have  occasionally  to  rely  exclusively  on 
Westphal's  symptom  in  our  diagnosis  of  the  case.  Dila- 
tation or  atrophy  of  the  coats  of  the  stomach,  on  the  other 
hand,  are  on  account  of  their  essentially  chronic-  course? 
not  likely  to  be  confounded  with  gastric  crisis. 

Cancer  of  the  stomach  occurs  mostly  in  advanced  age  ; 
there  are  almost  invariably  long-standing  symptoms  of 
indigestion,  with  pain  in  the  stomach,  whether  the  latter 
be  full  or  empty,  and  great  loss  of  appetite,  emaciation, 
and  a  greenish  or  jaundiced  complexion.  The  symp- 
toms do  not  vary  much  from  day  to  day,  but  it  should  be 
remembered  that  the  first  symptom  of  gastric  cancer  may 
be  hsematemesis.  Westphal's  symptom  will  in  any  doubt- 
ful case  clear  up  the  nature  of  the  affection. 

The  urinary  troubles  from  which  many  tabid  patients 
suffer  are  in  practice  frequently  referred  to  local  diseases  of 
the  urethra  or  bladder.  The  aid  of  the  bougie  or  catheter  is 
called  in,  and  the  patient  is  frequently  made  much  worse 
oy  this  local  interference.  There  can  be  no  doubt  that  the 
tabid  are  extremely  vulnerable  ;  and  if  the  symptoms 
described  on  p.  206  be  present,  the  surgeon  should  never 
omit  to  look  to  the  knee-jerk.  If  it  is  found  to  be  absent, 
local  instrumental  interference  can  in  most  cases  do  no 
good,  and  may  do  a  great  deal  of  harm.  I  am  inclined  to 
believe  that,  at  least  in  a  certain  number  of  those  cases  of 


THE  DIAGNOSIS  OP  TABES  SPINALIS.  287 

fatal  catheterism  which  Sir  Andrew  Clark  recently  brought 
before  the  Medical  Society  of  London,  incipient  tabes  may 
have  been  present.  It  is  true  that  it  was  stated  that  no 
post-mortem  change  was  discovered  in  any  important  organ ; 
but  it  is  at  least  possible  that  the  spinal  cord  may  not  have 
been  examined  with  all  due  care,  including  more  especially 
hardening  and  staining.  In  all  cases  of  impotency,  sperma- 
torrhcaa,  and  satyriasis  which  may  come  under  our  care  in 
practice,  a  special  search  for  other  symptoms  of  tabes 
should  be  instituted,  as  these  symptoms  acquire  an  entirely 
different  significance  when  owing  to  tabes,  from  what  they 
have  if  due  to  local  disorders  of  the  sexual  organs  and 
other  conditions. 

Attacks  of  hemiplegia  and  aphasia,  which  we  have  seen  to 
occur  in  tabes  (p.  194),  may  be  puzzling  unless  the  history 
of  the  case  be  known.  A  mistake  in  diagnosis  will  here  often 
lead  to  a  wrong  prognosis,  as  the  hemiplegia  and  aphasia  of 
tabes  are  almost  invariably  temporary,  and  not  owing  to  any 
structural  lesion  of  the  brain.  The  patellar  tendon  reflex 
is  here  again  of  the  greatest  semiotic  importance,  and  its 
loss  will  show  the  nature  of  the  case  more  definitely  than 
any  other  symptom. 

2.  The  second  or  ataxic  stage  of  tabes  shows  such  highly 
characteristic  features  at  first  sight  that  the  disease  can 
hardly  be  confounded  with  any  other  at  this  period  by  a 
competent  observer. 

It  has  been  stated  that  tabes  has  been  occasionally  con- 
founded with  chorea  ;  and  it  is  quite  true,  that  "  muscular 
madness  "  occurs  at  a  certain  period  of  the  ataxic  stage  of 
tabes  (p.  232),  as  well  as  in  chorea.  Nevertheless  it  seems 
almost  impossible  to  mistake  either  of  these  affections  for 
the  other.  Chorea  occurs  chiefly  between  five  and  fifteen 
years  of  age,  and  much  more  frequently  in  the  female 
than  in  the  male  sex  ;  moreover  the  choreic  twitches  occur 
spontaneously,  and  in  an  entirely  different  manner  from 
what  is  seen   in   ataxy.     It  seems  equally  impossible  to 


288  SCLEROSIS  OF  THE  SPINAL  CORD. 

mistake  tabes  for  paralysis  agitans,  in  which  the  chief 
symptoms  are  tremor  during  rest  and  loss  of  muscular 
power,  while  pain  is  ever  absent,  and  the  tendon  reflexes  are 
normal.  Other  forms  of  paralysis,  owing  either  to  cerebral 
or  spinal  disease,  are  distinguished  by  loss  of  muscular 
force,  which  latter  in  the  second  stage  of  tabes  is  almost 
invariably  normal.  In  ordinary  hemiplegia  and  in  trans- 
verse myelitis  the  patellar  reflex  is  increased,  unless,  what 
is  rarely  the  case,  the  lumbar  enlargement  should  happen 
to  be  aSected. 

Multiple  sclerosis  may  be  distinguished  from  tabes  chiefly 
by  the  peculiar  rhythmic  tremor  which  is  seen  when  volun- 
tary movements  of  a  certain  extent  are  made  or  intended  to 
be  made  ;  by  muscular  rigidity  ;  and  increase  of  the  tendon 
reflexes.  Disease  of  the  cerehellum,  such  as  tumour,  softening, 
etc.,  causes  a  staggering  or  "  reeling  "  gait,  like  that  of  a 
drunken  man,  with  an  impulse  to  fall  backward,  forwards, 
or  to  the  side  ;  the  patient  does  not  use  his  eyes  as  crutches  ; 
there  is  generally  severe  continuous  pain  in  the  back  of  the 
head,  which  often  extends  from  thence  in  gradually  dimin- 
ishing intensity  to  the  other  parts  of  the  head  ;  vomiting, 
optic  neuritis,  vertigo  even  in  the  horizontal  position  ;  no 
pain,  anaesthesia,  parsesthesia  or  analgesia  in  the  limbs  ;  and 
no  signs  of  ataxy  of  the  upper  or  lower  extremities  in  the 
horizontal  position. 

Chronic  spinal  meningitis  is  often  present  as  a  complication 
in  the  second  stage  of  tabes  (pp.  14,  42),  and  may  be  sus- 
pected when  there  is  much  pain  and  stiffness  in  the  back, 
with  tenderness  on  pressure ;  primary  spinal  meningitis, 
however,  cannot  be  confounded  with  tabes,  as  it  causes 
paralysis  with  muscular  rigidity,  and  no  ataxy. 

3.  The  terminal  stage  of  tabes  may  possibly  be  confounded 
with  the  terminal  stage  of  a  number  of  chronic  affections 
of  the  nervous  centres.  When  complete  paralysis  of  the 
bladder,  bowels,  and  lower  extremities  has  been  established, 
when  bed-sores  have  formed  on  the  sacrum,  the  heels,  and 


THE  DIAGNOSIS  OF  TABES  SPINALIS.  289 

other  parts,  when  the  patient  is  blind,  deaf,  emaciated  and 
helpless  to  the  last  degree,  then  we  have  indeed  to  deal 
more  with  approaching  dissolution  of  the  nervous  centres 
than  with  any  definite  localised  affection.  General  para- 
lysis of  the  insane  may  be  combined  with  tabes  in  various 
ways,  so  that  occasionally  the  cerebral  and  in  other  cases 
the  spinal  symptoms  predominate  ;  yet  in  more  definite 
and  less  diffuse  lesions  the  diagnosis  cannot  be  doubt- 
ful, in  many  cases  of  tabes  the  mind  remains  clear  and 
unclouded  to  the  last  ;  there  are  no  delusions  ;  speech  is 
rarely  much,  if  at  all,  affected,  and  the  pupils  are  equal.  In 
general  paralysis,  on  the  other  hand,  the  speech  is  always 
affected  ;  the  pupils  are  generally  unequal ;  there  is  tremor 
of  the  tongue  and  facial  muscles  ;  failure  of  memory, 
delusions,  and  imbecility.  In  cases  where  general  para- 
lysis becomes  complicated  with  tabes,  or  vice  versa,  the 
patellar  reflexes  are  absent ;  but  where  the  disease  is 
entirely  or  almost  entirely  cerebral,  these  reflexes  are  either 
normal  or  more  frequently  exaggerated. 


290  SCLEROSIS  OF  THE  SPINAL  CORD. 


CHAPTER  YIII. 

THE  PEOGNOSIS  OF  TABES  SPmALIS. 

As  late  as  1851,  Romberg  wrote  that  there  was  no  hope 
for  patients  of  this  class  ;  that  sentence  of  death  had  been 
passed  upon  them,  and  that  it  was  but  common  humanity 
to  inform  them  that  therapeutic  interference  could  only 
injure.  Trousseau,  in  1862,  said  that  the  prognosis  was  of 
extreme  gravity,  and  that  the  multiplicity  of  the  remedies 
used  for  combating  the  disease  testified  to  their  uselessness. 
Duchenne,  in  1877,  gave  a  somewhat  more  hopeful  view, 
and  laid  stress  on  the  importance  of  an  early  recognition 
and  persevering  treatment  of  the  complaint.  Vulpian,  in 
1879,  considered  the  prognosis  serious  ;  for  although  the 
disease  was  sometimes  arrested  and  for  a  time  even  im- 
proved, it  had  in  general  a  progressive  tendency,  and  the 
patient  must  die  of  it  unless  he  were  carried  ofi  by  some 
intercurrent  affection  ;  while  during  life  he  was  tortured 
by  pain,  sickness,  the  horrors  connected  with  the  affections 
of  the  bladder  and  bowels,  blind,  deaf,  unable  to  earn  his 
living,  and  entirely  dependent  upon  others.  In  1883, 
Ley  den  said  that  we  were  not  only  unable  to  cause 
the  lesion  of  tabes  to  disappear,  but  that  there  was  hardly 
any  prospect  of  our  ever  attaining  this  end  in  future. 

It  appears  to  me,  that  since  the  discovery  of  the  part 
which  syphilis  plays  in  the  etiology  of  tabes,  and  likewise 
since  the  discovery  of  a  symptom  which  allows  us  to 
recognise  the  latter  malady  in  the  very  beginning,  the 
aspect  of  this  question  has  become  entirely  changed.  We 
know  now  that    any   one   who   has   at  any  time   suffered 


THE  PROGNOSIS  OF  TABES  SPINALIS.  291 

from  constitutional  syphilis  may,  at  a  period  more  or  less 
remote  from  the  infecting  sore  and  the  secondary  manifes- 
tations, become  affected  with  tabes.  The  period  of  latency 
varies,  according  to  the  cases  which  have  been  reported  in 
this  volume,  from  twelve  months  (p.  95)  to  twenty-seven 
years  (p.  121);  and  a  patient,  therefore,  who  has  once  been 
syphilitic,  cannot  consider  himself  safe  from  the  liability  to 
tabes  for  the  better  part  of  his  life  afterwards.  This  fact, 
which  can  no  longer  be  disputed,  involves  a  serious  respon- 
sibility on  the  practitioner  who  has  to  treat  a  patient 
affected  with  venereal  disease.  We  have  seen  that  more 
especially  those  persons  who  suffer  from  comparatively  mild 
secondary  symptoms,  and  who  are  therefore  insufficiently 
treated,  become  later  in  life  the  victims  of  tabes  (p.  84) ; 
and  this  disease  would,  probably,  never  have  become  de- 
veloped in  them  if  the  syphilitic  taint  had  been  energeti- 
cally and  perseveringly  combated  at  the  time  of  its  first 
manifestations. 

When  the  venerable  Ricord  attended  the  meeting  of  the 
British  Medical  Association  at  Birmingham,  in  1873,  he 
delivered  an  address  in  which  he  stated  as  the  outcome  of 
his  unrivalled  experience  in  the  treatment  of  syphilis,  that 
a  patient  who  had  been  properly  treated  for  two  years  sub- 
sequently to  his  having  contracted  the  infecting  sore  was 
cured,  and  might  consider  himself  free  from  any  liability  to 
further  secondary  or  tertiary  manifestations. 

I  would,  therefore,  say  to  the  practitioner  :  Ponder  well 
over  Ricord's  teaching :  take  syphilis  well  in  hand  at  the 
earliest  stage  of  it.  Do  not  comfort  the  patient  who  comes 
to  you  with  an  infecting  sore  with  speedy  prospects  of 
a  cure,  but  tell  him  plainly  that  he  has  become  inoculated 
with  an  insidious  and  dangerous  poison,  which  may  maim 
or  kill  him  sooner  or  later  unless  he  submits  to  systematic 
and  persevering  treatment.  Do  not  rest  in  your  endea- 
vours until  you  have  reason  to  believe  that  every  germ  and 
vestige  of  that  fearful  virus  has  been  thoroughly  uprooted 

u2 


292  SCLEROSIS  OP  THE  SPINAL  CORD. 

and  destroyed.  Examine  those  of  your  patients  who  have 
had  secondary  symptoms,  from  time  to  time  for  the  knee- 
jerk  ;  inquire  of  them  whether  they  have  had  temporary 
double  vision  or  incontinence  of  urine  ;  examine  them 
for  Argyll-Robertson's  symptom ;  and  if  they  should 
complain  of  a  sensation  of  a  tight  rope  round  the  chest, 
do  not  at  once  rush  to  the  diagnosis  of  dyspepsia  and 
flatulence.  Do  not  thiok  that  every  severe  pain  in 
the  legs  is  owing  to  rheumatism  or  sciatica  ;  hunt  for  the 
symptoms  of  tabes  in  cases  of  grave  laryngeal,  gastric,  or 
intestinal  troubles,  which  may  have  been  preceded  by 
syphilis.  More  especially  should  you  find  the  knee-jerk 
absent,  take  it  to  be  a  warning  that  that  terrible  malady, 
tabes,  has  pushed  forward  its  outposts,  and  is  on  the  point 
of  invading  the  system.  Set  to  work,  then,  at  once  to 
obstruct  its  further  progress  by  every  means  in  your  power, 
and  let  us  thus,  by  suppressing  that  most  painful  disease, 
locomotor  ataxy,  add  one  more  triumph  to  the  victories  of " 

PREVENTIVE    MEDICINE  ! 

I  have,  then,  no  hesitation  in  stating  that  the  prognosis 
of  tabes  has,  in  consequence  of  the  advance  of  our  know- 
ledge of  the  causes,  the  early  symptoms,  and  last,  not 
least,  our  means  of  treating  the  disease,  become  much 
more  favourable  in  recent  years  ;  and  I  am  convinced  that 
when  the  malady  is  better  known  in  all  its  details  to  the 
entire  profession,  and  therefore  more  clearly  and  readily 
recognised  in  the  very  beginning,  the  prognosis  will  be- 
come more  favourable  still  as  time  goes  on.  In  cases  where 
the  primary  and  secondary  manifestations  of  syphilis  have 
been  insufficiently  treated,  the  patient  should  be  subjected 
to  a  prolonged  course  of  specific  treatment.  By  doing  this 
I  have  in  many  cases  of  this  kind,  in  which  the  prognosis 
appeared  to  be  prima  facie  extremely  unfavourable,  suc- 
ceeded in  arresting  the  further  progress  of  the  disease, 
and  in  preventing  any  subsequent  manifestations  of  the 
syphilitic  dyscrasia.     Some  patients,  in  whom  a  vast  deal 


THE  PROGNOSIS  OF  TABES  SPINALIS.  293 

of  mischief  had  already  been  done,  have  to  all  appearance 
permanently  recovered;  and  T  am  convinced  that  by  far 
the  largest  majority  of  them  w^ould  never  have  suffered 
from  syphilitic  disease  of  the  nervous  centres — which  is 
day  by  day  killing  many  persons  and  crippling  a  good  many 
more — if  the  primary  sore  and  the  earlier  secondary  symp- 
toms had  been  treated  in  that  systematic  and  persevering 
manner  v^hich  Ricord  has  shown  to  be  necessary. 

Although  we,  therefore,  look  upon  cases  of  tabes  no 
longer  as  hopeless,  we  must,  nevertheless,  not  disguise  from 
ourselves  the  fact  that  it  is  one  of  the  most  obstinate  com- 
plaints with  which  we  have  to  deal  in  practice;  that  some 
of  its  symptoms,  more  especially  optic  atrophy,  may  pos- 
sibly be  arrested  in  their  further  course,  but  that  any  actual 
mischief  which  has  been  done  in  such  parts  as  the  retina  is 
irreparable  ;  that  the  disease  is  never  a  mere  functional 
derangement,  but  at  the  very  beginning  one  of  destruction 
of  tissue;  and  that  the  patient  is,  therefore,  even  at  best, 
and  when  his  health  has  been  apparently  restored,  more 
vulnerable  than  another  whose  spinal  cord  has  never  suf- 
fered, and  less  able  to  stand  the  wear  and  tear  of  life  than 
he  was  previous  to  the  affection. 

I  now  proceed  to  consider  how  far  the  possibility  of 
recovery  in  tabes  is  limited  by  the  peculiarities  of  structure 
of  the  affected  parts,  and  of  the  disease  which  has  invaded 
them.  With  regard  to  the  latter,  it  must  always  be  kept 
in  mind  that  there  is  never,  at  any  time,  a  mere  functional 
or  prodromial  stage,  in  which  we  could  assume  that  we  had 
simply  to  do  with  finer  molecular  changes  in  the  nutrition 
of  the  affected  parts,  which  might  be  easily  rectified  ;  but 
that  there  is  actual  sclerosis  from  the  very  beginning. 

Experiments  in  animals,  more  especially  by  Eichhorst 
and  Schieferdecker,  have  shown  that  a  division  of,  or 
injury  to,  the  cord  may  to  some  extent  be  repaired,  more 
especially  where  the  injury  has  not  been  very  extensive, 
and  where  the  animals   are  young ;  and  that  this  repair  is 


294  SCLEROSIS  OF  THE  SPINAL  CORD. 

chiefly  seen  in  the  nerve-tubes,  and  much  less,  if  at  all,  in 
the  ganglionic  cells  of  the  grey  matter.  The  morbid 
anatomy  of  the  human  subject  has  shown  similar  results. 
In  patients  who  have  died  of  transverse  myelitis  as  well 
as  of  tabes,  newly  formed  nerve-tubes  have  been  found  by 
the  side  of  wasted  fibres,  and  apparently  originating  from 
them ;  and  the  persistence  of  the  axis-cylinder,  which  was 
formerly  believed  to  be  necessary  for  regeneration  of  the 
tube,  has  been  shown  not  to  be  indispensable.  Ganglionic 
cells,  which  are  more  highly  organised  than  simple  nerve- 
tubes,  appear  to  be  incapable  of  regeneration.  The  large 
cells  in  the  anterior  cornua  of  the  cord,  which  perish  in 
infantile  paralysis,  have  been  found  completely  wasted 
years  after  the  attack  of  that  disease  had  taken  place,  and 
even  after  considerable  recovery  of  motor  power  and 
muscular  tonicity  had  taken  place.  The  nerves  of  the 
higher  organs  of  special  sense,  which  have  a  particularly 
complex  and  highly  specialised  structure,  would  appear  to 
he,  prima  facie  incapable  of  repair.  Indeed,  it  is  found  that 
tlie  rods  and  cones  of  the  retina  and  the  fibres  of  the  audi- 
tory nerve  contained  in  the  crista  of  the  semicircular 
canals  of  the  membranous  labyrinth,  when  once  much 
injured  by  haemorrhage,  atrophy,  or  other  morbid  processes 
can  never  recover.  The  patient  whose  case  (No.  53)  is 
described  on  p.  176  got  perfectly  well  of  all  symptoms  of 
tabes,  except  of  the  deafness  which  had  been  caused  in 
him  by  an  attack  of  auditory  neuritis.  With  regard  to  the 
capacities  of  the  neuroglia  in  this  respect,  only  little  is 
known ;  and  equally  little  about  any  recuperative  power 
of  the  coats  of  the  blood-vessels  which  may  have  been 
pathologically  altered. 

Although,  therefore,  the  central  nerve-tubes,  which  are 
the  principal  seat  of  the  lesion  of  tabes,  have  been  shown 
to  be  capable  of  regeneration,  it  is  nevertheless  probable 
that  any  very  extensive  reproduction  of  them  is  rare,  more 
especially  in  persons  of  a  somewhat  advanced  age.     The 


THE  PROGNOSIS  OF  TABES  SPINALIS.  295 

cure  of  the  symptoms  of  the  disease  which  we  may  witness 
clinically  has  therefore  to  be  attributed  to  the  circumstance 
that,  apart  from  the   perished  or  incurably  diseased  fibres, 
others  have  been  in  a  state  of  only  commencing  degenera- 
tion,   which   latter    was     not    only   arrested,    but   actually 
repaired ;    while    again  others,    which    would    no    doubt 
eventually  have  succumbed  to  the  same  morbid  influence, 
were  spared  altogether.     More  especially  in  recent  cases, 
a   more  or    less    considerable    number    of    nerve-tubes    is 
left,  which  may  not  only  be  saved  from  destruction,  but 
which  may    be    considerably  strengthened  by  the  use  of 
proper  stimulants.    Finally,  the  ''  law  of  substitution  "  may 
become  to  some  extent  operative,  causing  healthy  fibres  in 
the  neighbourhood  to  perform  the  work   of  others  which 
have  perished.     If,    then,  we  observe  cHnically  that    the 
symptoms  of  tabes  gradually  improve  and  vanish,  we  must 
not  assume  that  all    the  anatomical  changes  which  have 
taken    place   in    the    central    nerve-tubes    have    been  re- 
paired;    but    that    there    has    been    improvement    in    the 
nutrition   of   those    fibres   whose    structure  was  not  irre- 
trievably damaged,   and  vicarious    action    on  the  part   of 
neighbouring  tracts. 

From  these  premises,  then,  it  appears  that,  under  favour- 
able circumstances,  the  two  principal  symptoms  of  tabes, 
viz.,  the  lightning-pains,  with  all  their  modifications  (crises, 
etc.),  and  the  locomotor  and  static  ataxy  may  wholly  or 
partly  yield  to  therapeutical  measures.  The  same  may  be 
said  of  the  vesical,  rectal,  and  sexual  troubles.  With  re- 
gard to  the  muscular  atrophy,  which  not  unfrequently 
accompanies  tabes,  less  hope  may  be  indulged  in,  as  we 
have  seen  that  ganglionic  cells,  when  once  destroyed,  are 
never  repaired.  Yet  we  must  not  lose  sight  of  the  fact 
that,  where  only  some  portions  of  these  cells  remain 
physiologically  active,  they  may  still  be  able  to  exert  a 
powerful  influence  on  nutrition  and  tonicity.  Adamkiewicz  ^ 
>  •*  Wiener  Medicinische  Presse,"  No.  9,  1883. 


296  SCLEROSIS  OF  THE  SPINAL  CORD. 

has  recently  seen  a  case  in  which  the  pressure  of  a  tumour 
in  the  left  side  of  the  cervical  enlargement  of  the  cord  had 
caused  the  ganglionic  cells  of  the  central  grej  matter  to  be 
reduced  to  the  thirty-second  part  of  their  original  size,  and 
yet  no  wasting  of  the  muscles  corresponding  to  the  injured 
parts  had  taken  place.  Finally,  the  optic  and  auditory 
atrophy  of  tabes  may  under  favourable  circumstances  be 
arrested  in  their  further  course ;  but  from  the  highly 
specialised  structure  of  the  involved  nerves,  a  repair  of 
destroyed  tissue  cannot  be  expected. 

The  prognosis  of  tabes  can  therefore,  on  the  whole,  at 
present  not  be  considered  so  dismal  as  most  of  the  autho- 
rities quoted  above  would  lead  us  to  believe.  We  possess 
in  mercury  and  iodide  of  potassium  true  specifics  for  the 
dyscrasia  which  in  the  enormous  majority  of  cases  leads  to 
tabes  ;  and  we  possess  likewise  in  electricity,  nitrate  of 
silver,  and  ergot  of  rye,  remedies  by  which  the  nutrition 
and  functional  activity  of  the  central  nerve-tubes  may  be 
wonderfully  promoted  and  stimulated.  Much  must  always 
depend  upon  the  time  when  the  patient  comes  under  treat- 
ment, upon  his  obedience  to  our  rules,  upon  his  age  and 
general  stamina,  as  well  as  upon  a  variety  of  more  indi- 
vidual circumstances.  While  we  cannot  hope  to  cure  the 
fully-developed  malady,  we  know  that  at  least  in  a  certain 
proportion  of  cases  where  the  disease  was  not  very  far 
advanced,  very  great  improvement,  and,  in  some,  more  or 
less  complete  recovery,  has  taken  place. 

The  patient  whose  case  is  described  on  p.  264,  and  who 
was  well  advanced  in  the  third  stage  of  tabes,  made 
wonderful  strides  towards  recovery  under  proper  treatment, 
until  an  unfortunate  relapse  into  dissipation  arrested  his 
progress,  and  killed  him.  Patients  who  give  themselves 
unreservedly  and  absolutely  up  to  our  rules  and  prescrip- 
tions, and  consent  to  live  by  command,  even  in  the  smallest 
details,  while  they  are  under  our  care,  have  an  infinitely 
better    chance    than  those    who    criticise   our   advice   or 


THE  PROGNOSIS  OF  TABES  SPINALIS.  297 

refuse  to  obey  us  implicitly.      Then  the  external  circum- 
stances of  the  patient  are  of  the  greatest  importance.    Out- 
patients   of   hospitals   have   no    chance  of  recovery  ;    the 
poor,  or  even  those  who  are  not  able  to  have  everything 
that  is  necessary  for  them,  should  be  admitted  as  in-patients 
at  the  earliest  possible  period.    Those  born  with  the  silver- 
spoon  in  their  mouths  are,  here  as  elsewhere,  the  favourites 
in  the  race  to  get  well.     Temperament  and  individual  con- 
stitution are  likewise   of  great    influence  :    the  rake  will 
succumb  more  quickly  than  the  philosopher.     Of  two  of 
the  most  marked  cases  of  tabes  which  I   ever  saw,  one 
occurred  in  a  peer,  who  being  of  slight  physique,  and  calm 
and  fastidious  by  temperament,   surrounded  himself  with 
everything  that  may   adorn  life,  and  found  consolation  for 
his  infirmity  in  the  arts  and  literature.      He  lived  to  the 
age  of  sixty,  after  having  been  subject  to  the  complaint 
for   upwards    of   thirty    years,    and   having    hardly    ever 
experienced  really  severe  suffering.      The  other  case  was 
that  of  a  hot-tempered  Irishman,  who,  after  having  made  a 
fortune  in  Australia,  returned  to  England  to  spend  his  life 
in  the  wildest  excitement,  intrigues,    and  debauchery  of 
every   description.      He   died  within  four  years  from  the 
outbreak    of    the    malady,     after   having   undergone    the 
most   frightful   tortures   which   man  may  be  called  upon 
to  endure,  and  having   seen  an   originally   herculean   con- 
stitution undermined  and  wasted  in  a  comparatively  short 
time. 

Generally  speaking,  the  natural  course  and  evolution  of 
tabes  are  slow.  A  number  of  years  will  mostly  elapse, 
even  without  active  treatment,  before  the  malady  becomes 
fully  developed  ;  and  there  is  on  the  whole  therefore  not  a 
great  tendency  on  the  part  of  it  to  shorten  life.  Many 
persons  suffering  from  it  reach  a  good  age ;  and  the  disease 
often  remains  stationary  for  many  months.  Nevertheless, 
patients  may  die  in  the  first  stage,  more  especially  in  con- 
sequence of  the  various   crises   to  which  they  are  subject, 


298  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  any  of  which  may  termmate  fatally.  Others  show, 
some  time  after  having  been  affected  with  tabes,  great 
loss  of  resistance  to  injurious  influences,  and  succumb 
to  bronchitis,  pulmonary  congestion,  and  similar  affec- 
tions which,  otherwise,  only  rarely  carry  off  men  in  the 
prime  of  life,  when  placed  in  favourable  circumstances. 
The  patients  also  seem  to  have  a  particular  tendency  to 
catch  typhoid  fever  and  similar  infectious  or  contagious 
diseases  ;  and  their  chances  of  surviving  for  any  length  of 
time,  are  therefore,  on  the  whole,  more  precarious  than 
those  of  others.  It  will,  however,  be  imprudent  even  in 
the  last  stage,  when  the  patient  is  hardly  more  than  a 
living  skeleton,  to  predict  a  fatal  result  within  a  short 
time,  as  in  some  cases  toughness  and  tenacity  are  seen 
in  place  of  vulnerability ;  and  although  the  patient  may 
be  said  to  be  dying  by  inches,  yet  the  process  of  dis- 
solution may  be  at  the  last  surprisingly  slow,  and  devoted 
and  intelligent  nursing  will  occasionally  rescue  the  patient 
from  the  very  jaws  of  death. 


299 


CHAPTER  IX. 

THE  TREATMENT  OF  TABES  SPINALIS. 

If  any  real  success  is  to  be  achieved,  the  treatment  of 
tabes  must  be  persevered  with  systematically  for  many 
months,  and  in  some  cases  for  years.  Rest  is  of  great  im- 
portance, and  we  must  endeavour  to  arrange  all  conditions 
of  life  as  favourably  as  possible  for  the  patient.  I  am  not 
a  partisan  of  absolute  rest,  either  mental  or  physical. 
Hammond  mentions  a  case  where  a  man  suffering  from 
tabes  was  obliged  to  keep  to  his  bed  for  twelve  months 
consecutively,  on  account  of  a  mismanaged  fracture  of  the 
thigh-bone,  and  who,  when  he  got  up,  was  found  to  be 
quite  free  from  ataxy.  This  I  believe  to  be  an  excep- 
tional occurrence,  as  complete  rest  for  a  considerable  time 
generally  makes  the  patient  more  lame  than  he  was  before, 
and  also  depresses  the  vital  powers  considerably.  I  there- 
fore, even  in  those  cases  where  walking  is  very  troublesome, 
encourage  the  patient  to  take  some  gentle  exercise,  as  far 
as  is  possible,  several  times  a  day. 

Excesses  of  every  description  must  be  strictly  prohibited. 
Indulgence  of  the  sexual  desire  is  more  particularly  baneful, 
and  alcoholic  intemperance  hardly  less  so.  The  patient 
whose  case  is  described  on  p.  264  was,  although  in  the 
third  stage  of  the  disease,  improving  in  every  respect 
under  treatment,  when  the  effects  of  a  drinking-bout 
carried  him  oft"  in  a  short  time. 

In  the  following  instance,  the  sexual  act  proved  very 
injurious  : — 

Case  73.  — In  September,  1882,  Dr.  Grasemann  re- 
quested me  to  see  a  manufacturer,  aged  fifty-two,  married, 


300  SCLEROSIS  OF  THE  SPINAL  CORD. 

who  had  for  the  last  four  years  complained  of  '^neuralgia  " 
in  the  left  arm,  chiefly  in  the  neighbourhood  of  the  deltoid 
muscle,  with  a  "  rheumatic "  swelling  in  the  left  thumb. 
The  case  looked  at  first  sight  like  one  of  rheumatic  gout  ; 
but  on  closer  inquiry  it  turned  out  that  the  patient  had 
had  syphilis  badly  twenty  years  ago  ;  that  the  knee-jerk  was 
gone  in  both  sides  ;  that  there  was  not  only  "  neuralgia," 
but  also  anaesthesia  and  analgesia  in  the  left  arm  ;  that 
the  patient  had  occasionally  had  shooting-pains  in  the 
right  arm  and  right  leg,  not  of  extreme  violence,  but 
nevertheless  of  a  severe  kind  ;  that  his  bladder  was  very 
sluggish,  and  his  sexual  power  diminished.  On  one 
occasion  lately,  when  he  had  had  intercourse,  it  was  of 
an  unsatisfactory  character,  and  immediately  afterwards 
he  felt  as  if  he  were  choking  or  fainting,  and  suffered 
from  such  an  amount  of  prostration  that  he  was  unable 
to  leave  his  bed  for  two  days.  At  the  same  time  all  the 
other  symptoms  from  which  he  had  suffered  had  become 
worse. 

Over-exertion  on  a  single  occasion  may  hurry  the  patient 
almost  immediately  from  the  second  into  the  third  stage  of 
tabes,  as  was  the  case  in  the  following  instance: — 

Case  74. — A  commercial  traveller,  aged  forty,  single,  was 
admitted  into  the  hospital  under  my  care  in  January,  1878. 
He  had  exceeded  in  drinking  and  sexual  indulgence  ;  had 
had  delirium  tremens  five  years  ago,  and  chancre,  gonor- 
rhoea and  stricture  before  then.  He  had  also  suffered  a 
good  deal  from  exposure  in  the  Tropics.  Two  years  ago 
he  first  felt  a  difficulty  in  walking,  and  was  then  ad- 
mitted into  the  hospital  at  Buenos  Ayres,  where  he 
remained  for  three  months,  and  got  better  and  worse,  off 
and  on.  At  present  there  is  ptosis  of  the  left  eyelid  and 
paralysis  of  the  rectus  internus  and  obliquus  superior  of 
the  left  eye.  There  is  no  sign  of  optic  atrophy,  and  no 
further  symptom  in  the  upper  portion  of  the  body.  Lower 
down  he  has  numbness  in  the  hips,  thighs,  legs,  and  feet. 


THE  TREATMENT  OF  TABES  SPINALIS.  301 

more  especially  the  latter  ;  lightning-pains  chiefly  in  the 
right  leg  and  foot,  but  occasionally  likewise  in  the  left. 
The  "shoots"  last  for  a  few  seconds,  after  which  he  is 
quiet  for  an  hour  or  so  ;  then  there  is  another  attack,  etc. 
He  feels  the  ground  as  soft  as  velvet.  Two  months  ago 
he  was  still  able  to  walk  three  miles  at  a  stretch,  when  one 
day,  on  crossing  a  street,  he  had  to  run  fast  in  order  to 
avoid  a  cab  going  over  him.  This  seemed  to  give  him  a 
strain  in  the  back,  and  ever  since  he  has  been  almost 
paralysed.  He  is  now  utterly  unable  to  walk,  even  with 
assistance,  although  he  has  little  difficulty  in  crossing 
one  leg  over  the  other,  and  in  moving  his  legs  in 
bed.  He  can  only  stand  when  supported  on  both  sides, 
and  would  fall  at  once  if  let  go.  When  standing  in  this 
fashion,  he  cannot  take  his  eyes  off  his  feet.  The 
bladder  is  weak  and  sluggish,  but  does  not  give  him 
much  trouble  ;  the  bowels  are  regular  ;  the  sexual  power 
is  diminished,  but  he  has  still  desire,  and  erections  and 
emissions  of  semen  in  his  sleep.  In  this  case  the  patient 
"jumped,"  as  it  were,  from  the  second  into  the  third  stage, 
as  he  became  completely  helpless  almost  directly  after 
running  a  few  steps. 

Smoking  does  not  seem  so  injurious,  and  a  cigarette 
or  a  mild  cigar  may  be  occasionally  allowed  to  those 
who  are  fond  of  this  pastime.  Exposure  to  cold,  on  the 
other  hand,  is  most  injurious  (p.  99),  and  should  be 
carefully  avoided. 

The  diet  must  be  nutritious  and  easily  digestible. 
Mutton,  either  roast  or  boiled,  poultry,  and  the  white 
kinds  of  fish,  such  as  sole,  whiting,  and  cod,  are  better 
than  the  heavier  meats  or  salmon.  Tea  and  coffee 
should  be  taken  in  strict  moderation ;  of  wines,  only 
claret  and  the  higher  class  of  red  Hungarian  wines  are 
to  be  allowed.  These  may  be  suitably  mixed  with  Salu- 
taris  or  Apollinaris  water.  Spirits,  sherry,  port  wine, 
the  heavier  Burgundies  such  as  Chambertin,  cliampagne, 


302  SCLEROSIS  OP  THE  SPINAL  CORD. 

and  bottled  beer,  should  be  avoided  altogether.  Where 
symptoms  of  general  debility  and  impaired  nutrition  are 
prominent,  phosphorus  and  cod-liver  oil,  or  malt  extract, 
are  useful.  Phosphorus  may  be  given  either  in  the  form 
of  the  French  pearl,  which  is  stated  to  contain  1-32 
part  of  a  grain,  but  probably  contains  only  half  that 
quantity ;  or  as  phosphide  of  zinc,  made  up  into  a  pill 
with  sugar  of  milk  and  glycerine  of  tragacanth,  the  dose 
of  this  being  a  quarter  of  a  grain. 

The  treatment  of  the  syphilitic  dyscrasia  is  of  paramount 
importance,  and  most  successful  when  carried  out  in  the 
first  stage  of  the  malady.  Mercury  is  here  our  sheet- 
anchor,  and  may  be  given  either  as  perchloride  or  biniodide, 
or  by  inunction.  The  latter  is  by  far  the  most  effective 
way  of  administering  the  medicine  ;  and  in  carrying  it 
out  I  greatly  prefer  the  oleate  of  mercury  to  the  dirty 
and  uncertain  blue  ointment  of  the  Pharmacopoeia,  in 
which  the  metal  is  rubbed  up  with  lard  and  suet.  In  the 
oleate  sixty  grains  of  the  red  oxide  of  mercury  are  to  be 
dissolved  in  ten  drachms  of  oleic  acid,  forming  a  ten  per 
cent,  solution,  of  which  as  much  as  a  whole  or  half  a 
teaspoonful  should  be  applied  at  bedtime  with  a  brush, 
and  then  covered  Avith  a  silk  handkerchief,  or  rubbed  by 
the  patient  himself  into  the  skin  for  a  few  minutes.  The 
inner  surfaces  of  the  thighs  and  arms  are  the  best  places, 
as  absorption  from  there  is  most  active.  This  application 
rarely  causes  much  irritation  ;  but  occasionally  an  ecthy- 
matous  rash  is  produced,  which,  however,  subsides  quickly, 
and  may,  if  necessary,  be  treated  by  astringent  lotions. 

Subcutaneous  injection  of  the  perchloride  of  mercury  is 
a  quick,  although  rather  painful,  mode  of  obtaining  the 
effects  of  the  metal  without  disordering  the  stomach.  The 
initial  dose  should  be  the  twenty-fourth  part  of  a  grain  of 
the  perchloride  dissolved  in  fifteen  minims  of  water.  This 
mode  of  treatment  can  only  be  carried  out  in  stout  persons, 
as  the  medicine  has  to  be  deeply  injected  into  the  cellular 


THE  TREAT3IENT  OF  TABES  SPINALIS.  303 

tissue  of  the  buttocks.  In  thin  persons  such  an  injection 
would  cause  a  considerable  degree  of  irritation.  If  no  re- 
action follows  the  injection  of  the  dose  mentioned,  it  may 
be  gradually  increased  to  the  sixteenth  or  twelfth  and  even 
sixth  part  of  a  grain,  and  be  repeated  daily  or  every  other 
day.  In  case  the  twenty-fourth  part  of  a  grain  should 
cause  irritation,  the  dose  may  be  further  diminished.  As 
much  as  half  a  grain  has  occasionally  been  injected,  but 
was  found  to  produce  symptoms  of  mercurial  intoxication. 
Liegeois  has  recommended  the  injection  of  morphia,  together 
with  the  sublimate,  the  formula  being — 

ft     Hydrargyri  perchloridi  . .  . .  gr.  iii- 

Morph.  hydrocUor.     . .  . .  . .  gr.  jss. 

Aq.  dest.  . .  . .  . .  •  •  o  ^^i- 

Misc.  fiat  injectio  hypodermica.     S.  Dose  15  minims 
(1-32  grain  of  the  perchloride). 

Other  preparations  of  mercury  recommended  for  injec- 
tion are  the  perchloride  of  mercury  and  sodium  (Stern), 
the  albuminate  of  mercury  (v.  Bamberger)  and  the  pep- 
tonate  of  the  metal  (Friedlsender).  None  of  them,  however, 
seem  to  possess  any  decided  advantage  over  the  per- 
chloride. 

There  is  no  necessity  for  causing  salivation.  If  the 
gums  should  be  slightly  touched,  and  the  mouth  be  un- 
comfortable, a  gargle  of  the  glycerinum  boracis  in  elder- 
flower  water  is  an  excellent  application. 

I  generally  combine  iodide  of  potassium  with  mercury 
in  the  beginning  of  the  treatment ;  and  this  may  be  given 
in  doses  varying  from  fifteen  to  one  hundred  and  twenty 
grains  per  diem.  Sometimes  it  is  found  that  the  larger 
doses  ao-ree  better  than  the  smaller  ones  ;  but  where  the 
stomach  refuses  to  take  the  drug  easily,  ammonia,  arsenic^ 
dilute  hydrocyanic  acid,  and  similar  correctives  must  be 
added. 

In  some  cases  the  iodide  of  sodium  acts  better  and 
more  pleasantly  than  the  potassium  salt  ;   but  the  latter 


304  SCLEROSIS  OF  THE  SPINAL  CORD. 

is  in  the  majority  of  cases  by  far  the  most  effective  of 
the  two. 

Increases  in  the  dose  of  the  iodide  must  be  made,  more 
especially  in  cases  which  progress  unfavourably,  and  where, 
after  a  short  improvement  in  the  symptoms,  a  somewhat 
rapid  deterioration  takes  place.  This  has  been  occasionally 
assumed  to  forbid  the  further  exhibition  of  the  drug,  with 
the  result  that  the  patient  has  become  hopelessly  diseased. 
Practitioners  are  still,  as  a  rule,  afraid  of  giving  large  doses 
of  this  medicine,  and  disinclined  to  continue  it  for  any 
length  of  time.  It  is,  however,  impossible  to  cure  the 
syphilitic  dyscrasia  with  five-grain  doses  of  the  drug 
given  twice  a  day  for  a  fortnight.  The  time  during  which 
mercury  and  iodide  of  potassium  should  be  continued,  and 
the  doses  in  which  they  are  to  be  given,  must  depend 
upon  the  individual  aspect  of  the  case. 

In  the  second  and  third  stage,  the  effects  of  the  specific 
treatment  are  not  nearly  as  marked  as  in  the  first.  Never- 
theless, it  is  our  duty  to  submit  the  patient  to  it,  unless, 
indeed,  his  system  has  already  become  saturated  with 
either  mercury  or  iodide  of  potassium.  In  this  latter  case, 
and  also  where  there  is  no  syphilitic  history,  we  have  to 
resort  to  the  use  of  ergot  of  rye  and  nitrate  of  silver. 

If  either  of  the  drugs  mentioned  or  the  application  of 
electricity  prove  useful  in  tabes,  after  the  specific  treatment 
has  failed  to  do  good,  this  is  no  proof  whatever  for  assum- 
ing that  the  affection  was  after  all  not  owing  to  syphilis. 
It  is  a  matter  of  daily  observation  that  maladies  or  symp- 
toms are  caused  in  the  first  instance  by  specific  blood- 
poisons,  such  as  gout,  syphilis,  diphtheria,  and  others, 
but,  after  having  existed  for  a  time,  acquire  an  individu- 
ality of  their  own,  and  demand  different  remedial  measures 
for  their  removal.  Thus  an  eczema  or  a  neuralgia  may 
originate  from  a  gouty  condition  of  the  blood,  but  may 
after  a  time  become  autonomous,  and  yield  rather  to  local 
applications  than  to  internal  remedies  intended  to  combat 


THE  TREATMENT  OF  TABES  SPINALIS.  305 

the  gout  J  diathesis.  In  the  same  manner  tabes,  although 
owing  to  and  first  set  up  by  sjphiUs,  may,  if  it  lasts  for 
a  number  of  years,  become  inaccessible  to  anti- syphilitic 
medication,  and  require  a  completely  different  treatment. 
I  have  never  seen  a  patient  more  thoroughly  syphilised 
than  the  one  whose  case  is  described  on  p.  264  ;  yet  he 
remained  uninfluenced  by  anti-syphilitic  treatment,  and 
improved  considerably  under  ergot,  silver,  and  electricity. 
The  patient  whose  case  is  related  on  p.  176,  recovered 
completely  under  the  influence  of  the  liquid  extract  of 
ergot,  given  in  doses  from  half  a  drachm  to  a  drachm 
three  times  a  day  for  about  eight  months  consecutively. 
It  was  a  case  in  which  there  was  no  history  or  evidence 
of  syphilitic  infection.  Ergot,  like  all  other  remedies,  is 
occasionally  disappointing,  but  is,  nevertheless,  a  very 
valuable  remedy  for  the  affection  which  we  are  now  con- 
sidering, even  where  there  is  a  history  of  infection. 

Case  75. — In  July,  1881,   I  was    consulted  by  a  mer- 
chant,  aged  forty-two,  married,  and  father  of  three  chil- 
dren, who  had   had  syphilis  ten   years   ago,  and  had  for 
the  last  three  years    suffered  from   lightning  pains,  with 
ataxic  gait,  together  with  Romberg's  and  Westphal's  symp- 
toms.    He  was    recommended   to  go  to  Aix-la-Chapelle, 
where  he  had  two  hundred  inunctions  without  the  least 
benefit.     I  now  put  him  on  ergot,  under  the  influence  of 
which  he  improved  considerably.     When  he  first  came  to 
me,  he  was  so  chilly  that  he  had  to  sit  in  his  office  quite 
covered  over  with  rugs  ;  the  bladder  was  so  irritable  that 
at  night  he  had  to  get  up  at  least  four  times  to  void  the 
urine,  and  frequently  wetted  the  bed.     He  was  subject  to 
bad  attacks  of  lightning-pains,  and  his  hands  and  feet  were 
so  benumbed  that  there  was  hardly  any  use  in  them.     Six 
weeks  afterwards  his  circulation  was   so  much  improved 
that  he  could  sit  for  hours  in  his  office  without  feeling 
chilly,  and  without  rugs ;  the  pain  was  much  less  severe  ; 
the  bladder  had  quieted  down  to  such  an  extent  that  he 

X 


306  SCLEROSIS  OF  THE  SPINAL  CORD. 

was  only  obliged  to  get  up  once  in  the  night  to  pass  his 
water,  and  he  no  longer  wetted  the  bed.  The  sensation 
in  his  hands  and  feet  had  become  normal,  and  he  walked  a 
great  deal  better. 

On  the  other  hand,  Grasset^  has  lately  seen  ergot  to 
do  harm  in  the  case  of  a  male  patient,  who  had  suffered 
from  tabes  for  some  years,  and  who  took  at  first  four 
grains  of  the  drug  per  diem,  and  had  this  gradually 
increased  until  he  took  fifteen  grains  per  diem.  On  the 
second  such  day  the  patient  appeared  to  have  lost  his  voice 
and  the  power  over  all  the  limbs.  Sensation  was  dimi- 
nished ;  he  had  no  pain,  but  he  could  neither  sit  up  nor  get 
up,  and  seemed  completely  paralysed.  The  ergot  was  then 
discontinued,  with  the  result  that  these  symptoms  dis- 
appeared, and  the  patient  gradually  returned  to  his  pre- 
vious condition.  This  must  be  a  very  rare  occurrence, 
as  I  have  never  seen  anything  even  approaching  to  it.  It 
shows,  however,  that  the  effects  of  the  drug  require  to 
be  carefully  watched.  Charcot  is  in  the  habit  of  giving 
ergot  for  four  days,  and  then  discontinues  it  for  the  next 
two,  and  so  on. 

Nitrate  of  silver  was  first  recommended  for  tabes  by 
Wunderlich  in  1858,  and  has  since  then  been  largely  used 
with  varying  results.  At  first  observers  were  unanimous 
in  their  praise  of  the  drug  ;  but  after  a  time  it  fell  into 
disuse,  and  it  is  at  present  not  so  favourably  looked  upon 
as  it  was  twenty-five  years  ago.  I  have  all  the  time,  since 
I  first  commenced  the.  use  of  this  preparation,  remained 
faithful  to  it  for  certain  cases,  more  especially  where  pain 
was  a  prominent  symptom,  and  have  often  seen  patients 
-.derive  great  advantage  from  it.  I  prescribe  it  chiefly  in 
those  cases  in  which  there  is  no  evidence  of  syphilitic 
taint,  and  where  patients  have  had  a  sufficiency  of  anti- 
syphilitic  treatment  without  being  apparently  much  the 
better  for  it,  as  far  as  the  cord-lesion  is  concerned.  I 
1 ''Progres  Medical,'' No.  11.     Paris,  1883. 


THE  TREATMENT  OF  TABES  SPINALIS.  307 

generally  give  it  in  doses  of  one-eighth  to  one-fourth  of  a 
grain.  It  is  important  to  recollect  that  all  organic  sub- 
stances reduce  nitrate  of  silver,  whether  in  substance  or  in 
solution ;  and  pills  prescribed  to  be  made  up  with  liquorice, 
taraxacum,  crumb  of  bread,  etc.,  are,  therefore,  practically 
inert.  This  explains  sufficiently  why  so  many  practi- 
tioners have  seen  no  good  results  from  the  use  of  this 
drug  ;  and  it  is  singular  to  find  so  excellent  a  chemist  as 
the  late  Peter  Squire^  directing  it  to  be  mixed  up  with 
crumb  of  bread,  which  contains  sufficient  chloride  of  sodium 
to  decompose  the  silver  completely.  I  have  for  years  past 
been  in  the  habit  of  prescribing  the  nitrate  to  be  made  up 
into  a  pill  with  argilla  or  bolus  alba  (silicate  of  alumina), 
which  cannot  possibly  decompose  it.  The  initial  pre- 
scription, ordering  the  eighth  part  of  a  grain,  reads  as 
follows  : — 

R.    Argenti  nitratis  . .  . .  . .       gr.  iii. 

Argillse  . .  . .  . .  . .       gr.  Ix. 

F.  c.  aq.  dist.  q.  s.  pilulse  no.  xxiv.,    obduc.  foliis 

argenti.    S.  a  pill  to  be  taken  twice  a  day  before 

meals. 

More  recently,  Martindale^  has  recommended  kaolin 
ointment  as  an  excipient.  Kaolin  is  native  silicate  of 
alumina,  which  has  been  purified  from  free  silica  and 
undecomposed  felspar,  and  is  made  up  into  an  ointment 
with  equal  parts  of  vaseline  and  paraffin. 

Shortly  before  or  after  taking  the  silver  pill,  the  patient 
must  not  take  anything  salty,  as  this  would  decompose 
the  nitrate,  and  form  insoluble  chloride  of  silver.  Our 
object  must  be  to  change  the  nitrate  in  the  stomach 
into  the  albuminate  of  silver,  which  is  soluble  in  diluted 
lactic  and  hydrochloric  acids,  and  may,  therefore,  be 
absorbed ;    while    chloride    of    silver,    which    is    formed 

'  "Companion  to  the  British  Pharmacopoeia,"  p.  44.     8th  edition, 

1871. 
2  «<  The  Extra  Pharmacopoeia,"  p.  50.     London,  1883. 

x2 


308  SCLEROSIS  OF  THE  SPINAL  CORD. 

when  table-salt  is  in  the  stomach,  and  also  when  some- 
what large  quantities  of  the  nitrate  are  taken,  is  only 
soluble  in  ammonia,  and  evacuated,  with  the  faeces.  It 
is,  therefore,  important  that  the  patient  should  not  par- 
take of  any  highly  salted  food  either  before  or  after  taking 
the  pill  ;  while  a  little  milk  taken  immediately  after  it 
would  tend  to  promote  the  formation  of  the  soluble  albu- 
minate. The  same  considerations  show  that  it  is  useless 
to  prescribe  large  doses  of  the  nitrate.  Silver  has  been 
found  in  the  urine  and  the  bile,  and,  if  given  for  a  consider- 
able time,  will  accumulate  in  different  parts  of  the  body. 

The  slaty  discoloration  of  the  skin  which  is  known  as 
argyria,  and  caused  by  the  prolonged  exhibition  of  the 
nitrate,  is  fortunately  now  only  rarely  seen  ;  and  it  must  be 
pronounced  unjustifiable  to  push  the  drug  so  far  as  to  per- 
manently disfigure  the  patient.  Argyria  when  once  estab- 
lished is  incurable,  the  silver  being  deposited  not  in  the 
epidermis,  but  in  the  corium.  Removal  of  the  epidermis 
by  means  of  blisters  has  therefore  not  the  least  effect ; 
nor  does  iodide  of  potassium  or  subsulphite  of  sodium, 
which  have  been  recommended  for  internal  use,  eliminate 
the  deposit.  It  is  therefore  our  duty,  when  prescribing  this 
preparation,  to  stop  short  of  a  quantity  which  would  cause 
discoloration.  Krahmer^  has  shown  that  the  minimum 
quantity  of  the  nitrate  which  will  produce  argyria  is 
four  hundred  and  fifty  grains.  The  highest  amount  given 
should  therefore  be  under  three  hundred  grains. 

According  to  Liouville,  Ollivier,  and  Friedreich,  albu- 
minuria is  apt  to  be  induced  by  a  prolonged  administration 
of  this  drug.  The  urine  should  therefore  be  examined 
from  time  to  tiine  while  the  patient  is  under  its  influence. 
I  must  say  that  I  have  never  found  a  trace  of  albumen  in 
the  urine  under  these  circumstances  ;  and  its  occurrence 
must  therefore  be  exceptional. 

*  Theodor  Husemann,  "  Handbucli  der  gesammten  Arzneimittellehre," 
vol.  i.,  p.  464.     2nd  edition.     Berlin,  1883. 


THE  TREATMENT  OF  TABES  SPINALIS.  309 

Tweedy,^  of  Dublin,  has  recorded  the  ease  of  a  patient 
affected  with  locomotor  ataxy  who  had  taken  it  persistently 
in  doses  of  one-third  of  a  grain  for  nearly  twelve  years. 
The  symptoms  of  ataxy  had  completely  disappeared,  but 
the  patient  had  become  argyrised,  and  showed  the  peculiar 
leaden  discoloration  of  the  skin.  On  the  other  hand, 
Riemer  ^  has  seen  a  case  of  tabes  where  a  patient  con- 
sumed altogether  5,672  pills,  and  the  first  tracer  of 
argyria  appeared  after  twelve  months'  use,  with  2,900 
pills,  containing  1,740  grains  of  the  nitrate,  or  1,104  grains 
of  metallic  silver.  This  patient  eventually  died  of 
phthisis,  and  there  had  been  no  improvement  in  the  tabes  ! 
The  peculiar  discoloration  was  discovered  after  death  not 
only  in  the  skin,  but  also  in  the  mucous  and  serous  mem- 
branes, the  blood-vessels,  kidneys,  mesenteric  glands,  and 
the  connective  tissue ;  the  substance  of  the  brain  and 
spinal  cord  did  not  contain  any  deposit,  but  the  choroid 
plexuses  and  the  pia  and  arachnoid  were  full  of  silver, 
while  the  dura  mater  showed  traces  of  it.  The  plexuses 
appeared  as  black  as  ink  to  the  naked  eye  ;  it  was  difficult 
to  dissociate  them  ;  the  tissue  had  lost  its  elasticity,  and 
the  silver  was  found  lying  in  dense  black  granules 
regularly  arranged  on  the  epithelium,  where  it  formed  a 
kind  of  silvery  membrane. 

Bokai,  ^  of  Pesth,  has  described  a  case  of.  tabes  in  which 
the  nitrate  taken  for  three  months,  in  doses  varying 
from  one-seventh  to  one-third  of  a  grain  per  diem,  cured 
the  patient.  Only  the  knee-jerk  remained  absent  on  both 
sides.  Two  years  afterwards  no  relapse  had  occurred. 
Of  course,  such  cases  are  exceptional ;  and  it  must  be 
confessed  that  nitrate  of  silver  often  proves  disappointing. 
Other  preparations,  such  as  the  oxide,  the  phosphide 
(Hamilton),  and  the  double  salt   of  iodide  of    silver  and 

*  *'  Medieal  Times  and  Gazette,"  March  24:tli,  1883. 
2  "  Archiv  fiir  Heilkimde,"  p.  296.  Leipzig,  1875. 
•''  *'  Orvoai  Hetilap,"  No.  43.     Buda,  1883. 


310  SCLEROSIS  OF  THE  SPINAL  CORD. 

potassium,  seem    to    be    even  less  certain  in  their  action 
than  the  nitrate. 

In  some  cases  I  have  found  the  subcutaneous  injection 
of  a  silver  salt,  as  recommended  by  Eulenburg,  extremely 
useful.     The  phosphate  has  the  disadvantage  of  not  being 
readily    soluble     in    water,    while    the    hyposulphite    is 
peculiarly  suited  for  this  administration.     The  formula  for 
this  is — 

Vk    Argenti  chloridi  recens  prsecipitati  gr.  iii. 

Sodii  subsulphitis        . .  . .  . .     gr.  xviii. 

Aquse  destill.   . .  . .  . .  . .     3  x. 

Misce  detur  in  vitreo  fusco.     i^    S.  For  subcutaneous 
injection.     Dose,  from  five  to  twenty  minims. 

The  same  precautions  should  be  taken  with  this  as  with 
the  injection  of  the  perchloride  of  mercury  (p.  302). 
Rosenthal  prefers  the  acetate  of  silver  for  hypodermic 
injection.  He  directs  three-quarters  of  a  grain  to  be 
dissolved  in  two  and  a-half  drachms  of  distilled  water, 
and  to  inject  of  this  ten  minims.  In  two  cases  out  of 
four  thus  treated,  there  was  striking  improvement. 

Chloride  of  gold  and  potassium,  which  has  been  recom- 
mended by  several  observers,  has  proved  completely  inert 
in  my  hands.  I  have  given  it  in  doses  varying  from  one- 
eighth  to  half  a  grain  for  several  months  consecutively. 

One  of  the  most  important  remedies  which  is  applicable 
to  all  cases  of  tabes,  whether  of  syphilitic  or  non-syphilitic 
origin,  is  electricity.  Duchenne  recommended  long  ago 
faradisation  of  the  skin  by  means  of  a  wire  brush,  in  com- 
bination with  iodide  of  potassium  and  mercury,  and  stated 
that  he  had  seen  good  results  from  its  use.  This  pro- 
ceeding, which  had  for  many  years  fallen  into  disuse,  has 
recently  again  been  strongly  recommended  by  Rumpf,^ 
of  Bonn,  who  recommends  to  faradise  the  back,  as  well  as 
the  limbs,  systematically  for  ten  or  twelve  minutes  each 
time.     This  proceeding  appears  to  have  occasionally  been 

*  "  Aerztliches  Vereinsblatt,"  No.  10,1881;  "  Neurologisches  Cen- 
tralblatt,"  Nos.  1  and  2,  1882. 


THE  TREATMENT  OF  TABES  SPINALIS.  311 

successful  in  his  hands.  The  current-strength  should  be 
such  as  to  cause  contractions  of  the  muscles  supplied  by 
the  median  nerve  on  applying  the  brush  to  the  latter  at 
the  bend  of  the  elbow.  There  is  no  question  that  the 
cord  is  reflexly  affected  by  this  proceeding,  and  it  is  pro- 
bably owing  to  this  that  any  therapeutical  results  are 
obtained.  I  prefer  faradisation  of  the  skin  as  an  aid  to 
the  constant  current,  rather  than  as  a  substitute  for  it. 

Faradisation  of  the  skin  in  tabes  requires  great 
familiarity  with  the  practice  of  medical  electricity,  if  it  is 
to  do  good.  An  excessive  dose  may  do  great  harm  ;  and 
the  operator  must  be  well  acquainted  with  the  different 
degrees  of  susceptibility  of  the  skin  in  different  parts  of 
the  body  to  faradism.  The  wire  brush  used  should  have 
a  large  surface,  not  less  than  the  size  of  half-a-crown, 
and  must  be  quite  soft.  The  small  prickly  brushes 
usually  sent  out  with  induction-machines  are  worse  than 
useless.  Messrs.  Coxeter  and  Son  have  made  a  very  nice 
wire  brush  for  me,  which  can  be  strongly  recommended. 
The  current-strength  used  must  always  be  moderate,  and 
proportionate  to  the  state  of  sensibility.  Where  anae- 
sthesia is  present,  more  force  should  be  used  than  where 
sensation  is  not  much  impaired.  I  have  at  present  a 
patient  under  my  care  for  whom  I  use  on  the  left  side 
six,  and  on  the  right  side  eighteen,  degrees  of  Stohrer's 
induction-machine. 

As  far  as  electricity  is  concerned,  however,  we  must  look 
to  the  constant  current  as  our  sheet-anchor  in  these  cases. 
The  constant  current  is  not  able  to  restore  central  nerve- 
tubes  which  have  been  destroyed  ;  but  it  has  the  tendency, 
by  its  catalytic  and  stimulating  effects,  to  improve  the 
nutrition  of  those  which  are  beginning  to  be  diseased,  to 
strengthen  the  remainder,  and  also  to  some  extent  to  call 
into  play  the  law  of  substitution,  thus  causing  healthy 
fibres  in  neighbouring  strands  to  perform  the  work  of  others 
which  have  perished. 


312  SCLEKOSIS  OF  THE  SPINAL  CORD. 

The  merit  of  having  introduced  the  constant  current  into 
the  therapeutics  of  tabes  belongs  to  Remak,  sen.,  whose 
publications  were,  however,  more  those  of  the  enthusiast 
than  of  the  sober  observer  (1858).  Subsequently  this  treat- 
ment was  largely  resorted  to  by  Benedict  of  Vienna,  Moritz 
Meyer  of  Berlin,  and  myself,  with  the  result  that  the 
remedial  value  of  this  form  of  electricity  in  tabes  was 
placed  beyond  dispute.  More  recently  Erb  and  his  pupils 
have  added  their  testimony  to  ours,  and  at  present  there  are 
few  cases  of  tabes  which  are  not  subjected  to  this  mode  of 
treatment.  Insufficient  acquaintance  with  the  technicalities 
of  the  electric  treatment  has,  however,  frequently  been  a 
source  of  disappointment.  It  is  not  desirable  that  the 
novice  in  electro-therapeutics  should  win  his  first  spurs 
in  cases  of  tabes.  Patients  of  this  kind  are  generally 
extremely  sensitive,  and  errors  in  the  mode  of  application 
are  apt  to  be  punished  by  a  speedy  deterioration  of  their 
condition. 

The  principal  rule  in  applying  the  current  is,  that  the 
applications  should  be  short  and  gentle.  I  frequently  use 
only  one  or  two  milliamperes,  and  consider  Lowenfeld's^ 
recommendation  of  five  to  fifteen  milliamperes  risky.  We 
must,  however,  act  according  to  individual  circumstances  ; 
for  where  the  principal  symptoms  are  anaesthesia  and  loss  of 
power,  a  greater  current- strength  may  be  used  than  where 
we  have  to  do  with  lightning-pains,  parsesthesia,  and  ten- 
dency to  crises  of  different  kinds.  The  application  of  large 
electrodes  (about  five  inches  by  two)  to  the  spine  is  the 
most  important  proceeding.  Here,  again,  the  aspect  of  the 
individual  case  has  to  guide  us  to  a  considerable  extent. 
Where  signs  of  irritation  preponderate,  the  cathode  should 
be  placed  at  a  distance  from  the  spine.  In  such  cases  I 
put  the  large  anode  to  the  region  of  the  lumbar  enlarge- 
ment, and  the  cathode  to  the  epigastrium,  for  two,  three  or 

^"Ueber  den  gegenwartigen  Stand  der  Therapie  der  chronischen 
Riickenmarkskrankteiten,"  p.  20.     Miinchen,  1884. 


THE  TREATMENT  OF  TABES  SPINALIS.  313 

four  miimtes  at  a  time  ;  afterwards  I  place  the  anode  to  the 
cervical  spine,  and  the  cathode  on  the  sternum,  for  from  two 
to  four  minutes.  Where  debility  without  irritation  seems 
prominent,  the  cathode  is  placed  to  the  cervical  spine,  and 
the  anode  immediately  below  it  ;  the  latter  is  left  in  situ 
for  a  minute,  or  a  little  more,  then  moved  further  down,  left 
on  again,  and  so  until  the  whole  of  the  spine  has  received 
its  influence,    the    whole    application    lasting    about    five 

minutes. 

Moritz  Meyer  and  Erb  prefer  the  application  of  the 
cathode  to  the  region  of  the  cervical  sympathetic  nerve, 
the  anode  being  placed  to  the  opposite  side  of  tlie  spine, 
and  gradually  conducted  downwards.  This  is  a  useful 
application,  but  is  frequently  not  well  borne,  as  shown  by 
giddiness,  swimming  in  the  head,  buzzing  in  the  ears,  and 
other  impleasant  symptoms.  I  therefore  prefer  one  of  the 
direct  applications  to  the  spine  which  I  have  mentioned, 
with  a  current  of  moderate  force,  and  then  add  a  still 
more  gentle  application  to  the  sphere  of  the  cervical 
sympathetic  nerve,  for  one  or  two  minutes  at  a  time  at 
each  side.  For  the  latter  I  have  occasionally  used  only 
the  fifth  or  tenth  of  a  milliampere,  and  yet  with  decided 

results. 

Neftel  recommends  an  application  to  the  head  as  well  as 
to  the  spine.  For  the  latter  he  places  the  cathode  to  the 
neck,  and  the  anode  to  the  lumbar  spine  ;  he  begins  with  a 
feeble  current,  which  is  then  gradually  increased.  After 
three  minutes  the  current- strength  is  again  diminished,  and 
the  anode  is  then  passed  several  times  slowly  down  the 
spine,  over  the  spinous  as  well  as  the  transverse  processes. 
Meyer  and  Brenner  speak  highly  of  the  application  of  the 
current  to  tender  points,  which  may  be  discovered  about 
the  spine.  Such  tender  points  are,  however,  only  rarely 
met  with,  and  it  is  still  doubtful  whether  much  importance 
is  to  be  attached  to  them. 

Certain  local  applications  of  the  current  may  be  also 


314  SCLEROSIS  OF  THE  SPINAL  CORD. 

used  with  advantage,  in  order  to  stimulate  the  action  of  the 
bladder  and  the  bowels,  to  relieve  pain  and  anaesthesia,  etc. 
These,  however,  should  only  play  a  secondary  part  in  the 
treatment,  the  central  applications  being  always  the  most 
important. 

Galvanic  or  faradic  baths,  as  at  present  used,  constitute  a 
form  of  quackery  which  should  be  strongly  discountenanced 
in  the  treatment  of  tabes. 

Another  means,  of  which  some  observers  have  seen  con- 
siderable results,  is  water  in  the  widest  sense  of  the  word. 
Patients  with  tabes  are  frequently  treated  in  hydropathic 
establishments,  and  the  peculiar  fervour  which  is  charac- 
teristic of  most  water-doctors  has  been  shown  in  their 
reports  of  the  success  achieved  in  such  cases.  It  has, 
however,  gradually  been  ascertained  that  the  various 
applications  of  hot  as  well  as  cold  water  do  harm  in  place 
of  good.  Sea-baths,  vapour  and  Turkish  baths,  ordinary 
cold  baths,  the  douche  in  its  various  forms,  and  those 
mineral  baths  the  chief  feature  of  which  is  their  heat,  often 
cause  a  rapid  deterioration  in  the  state  of  the  patient.  On 
the  other  hand,  it  has  been  found  that  tepid  baths,  of  a 
temperature  varying  from  80°  to  90°,  and  of  short  duration, 
that  is  to  say,  from  four  to  ten  minutes,  act  beneficially  ; 
and  this  principle  holds  good  not  only  for  ordinary  water, 
but  also  for  mineral  waters. 

Rosenthal^  states  that  a  judicious  hydrotherapeutic 
treatment  allays  central  irritation,  strengthens  the  nervous 
system,  and  diminishes  its  undue  excitability  and  the  dan- 
gers to  which  it  is  exposed  on  account  of  its  sensibility  to 
atmospheric  changes.  He  recommends  chiefly  friction  with 
a  cloth  dipped  in  water  between  65>^  and  65° ;  a  cold  com- 
press should  be  applied  to  the  head,  and  the  patient  be 
placed  in  a  bath  of  75°  to  68°,  into  which  cold  water  is 
slowly  poured  until  the  temperature  is  lowered  to  64°  or 

^"Diseases  of  the  Nervous  System,"  vol.  i.,  p.  259.  (American 
edition.)    New  York,  1879. 


THE  TREATMENT  OF  TABES  SPINALIS.  315 

61°.  The  patient  should  remain  in  this  bath  from  four  to 
eight  minutes  ;  he  is  then  showered,  and  friction  applied  to 
the  back.  When  the  procedure  is  over,  the  patient  should 
feel  thoroughly  comfortable,  and  be  enjoined  to  take  some 
exercise  in  the  open  air. 

Mineral  waters  and  baths  have  been  employed  for  the 
cure  of  tabes  ever  since  the  disease  has  been  known,  and 
generally  with  unfavourable  results.  The  thermal  springs 
of  Gastein,  Wildbad,  Teplitz,  and  other  similar  Spas,  which 
are  so  useful  for  many  forms  of  rheumatism,  gout,  neur- 
asthenia, and  other  conditions,  are  utterly  unsuitable  for 
tabes.  The  journey  to  and  from  a  Spa  alone  often  does 
a  great  deal  of  harm.  In  recent  years  the  brines  of 
Oeynhausen  and  Nauheim  have  acquired  considerable 
reputation.  I  regret  to  say  that  I  am  unable  to  speak 
well  of  their  effects.  All  the  patients  whom  I  have  sent 
to  Oeynhausen  returned  in  a  worse  condition  than  they 
left  :  one  had  a  stroke  of  paralysis  while  there ;  and  in 
another,  soon  after  his  return  home,  an  acute  form  of 
general  paralysis  of  the  insane  supervened,  rendering  it 
necessary  that  the  patient  should  be  placed  under  restraint. 

The  Aix-la-Chapelle  treatment,  which  under  the  auspices 
of  Drs.  Brandes,  Reumont,  Schumacher  II.,  and  others, 
has  become  an  established  institution,  consists  of  the 
simultaneous  use  of  mercurial  inunction  and  the  external 
and  internal  use  of  the  sulphurous  waters  of  that  Spa.  It 
is  believed  that  by  the  use  of  these  different  agents  at  the 
same  time,  more  benefit  is  produced  than  by  either  of  them 
singly ;  and  there  can  be  no  doubt,  from  the  positive  state- 
ments of  reliable  observers,  that  the  Aix-la-Chapelle  treat- 
ment is  frequently  successful  in  tabes.  It  is,  perhaps,  in 
the  nature  of  things  that  I  should  only  have  seen  patients 
in  whom  it  has  been  either  useless  or  appeared  to  do  harm  ; 
yet  I  have  found  this  so  frequently  to  be  the  case  that  I 
feel  it  incumbent  upon  me  to  reserve  my  judgment  about 
the  real  merits  of  the  Aix-la-Chapelle  treatment  in  tabes. 


316  SCLEEOSIS  OF  THE  SPINAL  CORD. 

French   observers  express    the  highest   opinion   of    the 
mineral  waters  of  La  Malou,  near  Montpellier,  in  the  de- 
partment  of  I'Herault,   which   contain  iron,    alkalies,   and 
traces  of  arsenic,  with  carbonic  acid  gas,  besides  which  they 
have  a  high  temperature.     Grasset  ^  quotes  some  wonderful 
cures  from  a  little  book  of  Privat's,  which  are  worth  men- 
tioning.    A  man,  aged  thirty-seven,  fell  into  the  water  in 
winter,  and  was  obliged  to    keep  his  wet   clothes   on  for 
eight  hours  subsequently.    Five  weeks  afterwards  lightning- 
pains,  constipation,  sluggishness  of  the  bladder,  and  sexual 
debility  supervened.     Fifteen  months  afterwards  there  was 
right  ptosis  and  double  vision,  ataxy,  incontinence  of  the 
urine,  impotency,  and  anaesthesia  in  the  lower  limbs.     In 
this  state  the  patient  arrived  at  La  Malou,  walking  with 
crutches.     He  took  twenty  baths,  after  which   the    pains 
disappeared,  and  he  was  enabled  to  return  to  work.     Three 
years  afterwards,  however,  he  had  a  relapse  owing  to  ex- 
posure,  and  the  disease  after    that    ran  its  usual  course. 
More  extraordinary  is   the   case  of  a   doctor  who  was,  at 
twenty-nine  years  of  age,  affected  with  erratic  pains,  motor 
incoordination,  strabismus,    paralysis    of  the   third  nerve, 
gastralgia,  dyspepsia,  obstinate  constipation,  sluggishness 
of  the  bladder,  absolute  impotency,  and  plantar  anaesthesia. 
This  went   on  for  eight  years,   the  last  two  of  which  he 
spent  in  his  room  or  bed.     Two  successive  seasons  at  La 
Malou  were  followed  by  considerable  improvement.     The 
year  after  he  did  not  return  there,  and  lost  what  he  had 
gained.     He  then  came  back,  and  had  two  courses  of  treat- 
ment annually,  for  four  or  five  years  consecutively.     The 
pain  gradually    diminished  ;  the  motor  power   was  fully 
re-established  ;    and  ultimately  the  plantar  anaesthesia  dis- 
appeared nineteen  years  after  the  beginning  of  the  malady. 
Tabes  in  La  Malou  seems  occasionally  to  assume  extra- 
ordinary forms ;  thus  Privat  mentions  the  case  of  a  man 

^    "Traite  Pratique  des  Maladies  du  Systeme  Nerveux,"  p.  338. 
2nd  Edition.    Montpellier,  1881. 


THE  TREATMENT  OP  TABES  SPINALIS.  317 

who  could  only  walk  with  the  aid  of  a  stick  or  an  arm, 
but  who,  during  his  crises  of  somnambulism,  which  came  on 
every  eight  or  ten  days,  could  walk  quite  easily  and  without 
a  stick !  Seeing  the  extraordinary  benefit  which  patients 
seem  to  derive  at  La  Malou,  it  is  singular  to  find  Grasset 
stating,  almost  on  the  same  page,  that  "  the  prognosis  of 
tabes  is  most  serious,  and  that  it  is  an  incurable  disease  "  ! 
The  description  of  the  cases  just  given  is  not  sufficiently 
detailed  to  enable  me  to  speak  definitely  about  their  nature; 
but  as  Charcot  and  Combal,  of  Montpellier,  appear  to  send 
patients  with  tabes  habitually  to  La  Malou,  it  is  possible 
that  the  treatment  there  may  occasionally  do  good.  We 
must,  however,  be  cautious  in  accepting  the  statements  of 
local  Spa  doctors,  who  are  invariably  inclined  to  take  a 
rose-coloured  view  of  the  effects  of  their  own  waters. 

Nerve-stretching,  for  the  relief  or  cure  of  tabes,  has  had  a 
short  and  not  very  brilliant  career.  The  operation  was 
originally  introduced  into  surgical  practice  by  Nussbaum, 
of  Munich,  in  1872,  for  the  relief  of  pain,  and  proved 
successful  in  an  intractable  case  of  "  painful  spasm  in  the 
left  arm."  The  first  English  surgeon  who  performed  the 
operation  was  the  late  Mr.  Callender,  who  cured  a  neuralgia 
in  an  amputation- stump  by  stretching  the  median  nerve 
(1875),  Since  then  nerve-stretching  has  been  frequently 
resorted  to,  in  the  belief  that  the  effects  of  it  were  peri- 
pheral, but  more  decided  than  those  of  neurotomy  or  neu- 
rectomy. It  was  assumed  that  the  molecular  condition  of 
the  nerve  was  altered  ;  that  undue  excitability  in  the  motor 
as  well  as  in  the  sensory  sphere  was  diminished  ;  and  the 
success  of  the  proceeding  was  ascribed  to  the  breaking  up 
of  adliesions  of  the  nerve  with  the  surrounding  tissues. 
Vogt^  of  Greifswald,  whose  able  essay  on  this  subject  ap- 
peared in  1877,  came  to  the  conclusion  that,  by  stretching, 
the  nerve-fibres  were  separated  from  the  neurilemma,  that 
the  blood-vessels  in  the  sheath  of  the  nerve  were  stretched 

'  '*  Die  Nervendehnung  in  der  chirurgischen  Praxis."    Leipzig,  1877. 


318  SCLEROSIS  OF  THE  SPINAL  COED. 

and  loosened,  and  that  thereby  the  nutrition  of  the  nerve 
itself  was  improved.  He  denied  that  the  operation  had 
any  influence  on  the  nervous  centres. 

In  1879,  the  medical  world  was  startled  by  a  publication 
of  Langenbuch,^  of  Berlin,  in  which  nerve-stretching  was 
strongly  recommended  for  the  cure  of  tabes.  A  patient, 
who  was  believed  to  be  suffering  from  that  disease,  was 
subjected  to  stretching  of  the  sciatic  and  crural  nerves, 
apparently  with  benefit  as  far  as  pain  and  ataxy  were  con- 
cerned. Three  months  afterwards,  the  pain  being  severe  in 
the  arms,  the  brachial  plexus  was  stretched  by  the  same 
surgeon,  with  the  result  that  the  patient  was  seized  by  an 
epileptiform  convulsion,  and  died  on  the  operating-table. 
The  spinal  cord  was  sent  to  Professor  Westphal  for  exami- 
nation, and  he  found  that  the  case  had  not  been  one  of 
tabes,  nor  indeed  of  any  spinal  disease. 

Although,  therefore,  the  first  step  in  this  matter  was 
hardly  encouraging,  Langenbuch  nevertheless  continued  to 
operate  on  patients  suffering  from  tabes,  and  started  the 
theory  that  this  operation  had  a  beneficial  influence  on  the 
nervous  centres.  He  stated  that,  by  stretching,  the  morbid 
products  of  sclerosis  were  necrosed,  and  therefore  rendered 
fit  for  absorption,  while  the  operation  at  the  same  time 
afforded  a  powerful  stimulus  to  the  remainder  of  healthy 
nerve-tubes,  and  thus  enabled  them  to  do  their  work  better. 
Carried  away  by  his  enthusiasm  for  this  procedure,  the 
same  surgeon  actually  stretched  the  nerves  of  the  sphincter 
ani  for  tenesmus  of  the  bowel,  and  the  pudendal  nerves  in 
order  to  stop  the  habit  of  masturbation ! !  The  latter  opera- 
tion was  followed  by  septicaemia,  convulsions,  and  death. 

^"tjber  Dehnung  grosser  Nervenstamme  bei  Tabes  Dorsalis.'* 
"Berliner  klin.  Wocbenscbrift,"  No.  49,  1879;  also  Nos.  24  and  27, 
1881  ;  also  Nos.  12  and  13,  1882.  La,ngenbicch  has,  more  especially  in 
tbis  country,  been  frequently  confounded  with  the  veteran  surgical 
master,  Von  liaiigeiibeck  ;  and  on  account  of  the  similarity  of  the  two 
names,  particular  attention  has  been  directed  to  this  matter. 


THE  TREATMENT  OP  TABES  SPINALIS.  319 

Langenbuch's  publications  naturally  aroused  much  atten- 
tion in  the  city  where  he  performed  his  operations  ;  and 
the  results  which  he  asserted  had  been  obtained  were  sub- 
jected to  a  somewhat  searching  criticism,  which  proved 
decidedly  unfavourable.  Thus  he  had  reported  a  case  as 
greatly  improved,  which  had  been  seen  by  Remak,  jun., 
both  before  and  after  the  operation  ;  and  Remak  reported 
that  the  patient  was  worse  after  the  stretching.  In  another 
case  of  quite  recent  tabes,  Bernhardt  reported  that,  six  weeks 
after  the  operation,  the  right  leg,  in  which  the  crural  nerve 
had  been  stretched,  was  paralysed  ;  that  the  patient  then 
suffered  from  severe  intercostal  neuralgia,  and  some  time 
afterwards  had  lightning-pains  in  the  legs.  Before  the 
operation  the  patient  could  walk  pretty  well,  but  five 
months  afterwards  his  legs  were  quite  useless.  In  a  third 
case,  in  which  Langenbuch  had  reported  improvement  in 
cutaneous  and  muscular  sensibility,  in  walking,  urination, 
the  function  of  the  sexual  organs,  etc.,  Bernhardt  found  the 
patient  in  exactly  the  same  condition  in  which  he  had  been 
before  the  operation. 

Nerve-stretching  is  by  no  means  devoid  of  risk.^  A 
somewhat  considerable  number  of  fatal  cases  has  been  re- 
corded by  Socin,  Billroth,  Berger,  Benedict,  Riegner,  Hahn, 
Miiller,  Gussenbauer,  Hirschfelder,  Fluger,  and  others. 
In  some  of  these,  undue  violence  in  stretching  appears  to 
have  been  the  cause  of  death,  the  medulla  oblongata  having 
apparently  received  a  shock  at  the  time  of  the  operation. 
In  one  case,  severe  vomiting  and  singultus,  together  with 
complete  paralysis  of  the  bladder  and  bowels,  supervened 
after  the  operation  ;  dyspnoea  and  cyanosis  eventually  set 
in,  and  the  patient  died  comatose  on  the  ninth  day.  In 
other  cases  the  patients  have  died  of  blood-poisoning  from 
septicaemia,  owing  chiefly  to  infection  of  the  wound  by  the 
urine  and  faeces,  etc. 

'  Vide  my  note  on  "The  Dangers  of  Nerve-stretcMng,"  "British 
Medical  Journal,"  Jan.  7,  1882. 


320  SCLEROSIS  OP  THE  SPINAL  CORD. 

The  literature  on  nerve-stretcMng  is  already  so  enormous 
tliat  it  is  utterly  impossible,  in  the  limits  of  the  present 
treatise,  to  even  allude  to  all  the  experiments  which  have 
been  made  on  this  subject  ;  and  we  must  refer  those  more 
particularly  interested  in  it  to  the  admirable  lecture 
recently  delivered  by  John  Marshall  before  the  College  of 
Surge6ns,  and  to  the  able  and  pains-taking  treatise  of 
Stintzing^  of  Munich.  The  latter  concludes  from  his 
experiments  on  animals  that  stretching  a  healthy  mixed 
nerve  has  in  general  a  paralysing  effect  on  the  same? 
which  extends  pretty  equally  to  the  motor,  sensory,  vaso- 
motor, and  trophic  fibres.  The  degree  of  the  paralysis  is 
proportional  to  the  force  used  in  stretching,  and  the 
symptoms  correspond  on  the  whole  to  those  of  degenerative 
atrophy  of  the  nerves,  although  they  show  numerous 
deviations  from  the  typical  course  of  the  latter.  Even 
where  the  paralysis  has  progressed  very  far,  and  where 
the  force  used  in  stretching  has  been  more  than  half  the 
bodv-weight  of  the  animal,  repair  to  a  considerable  extent 
may  take  place. 

These  results  are  certainly  very  far  from  encouraging, 
and  do  not  afford  any  explanation  of  the  slight  therapeu- 
tical effects  which  have  unquestionably  in  a  few  cases 
been  obtained.  Stintzing  has  given  a  careful  description 
of  four  cases  of  tabes,  in  which  Nussbaum  stretched  the 
sciatic  nerve,  either  by  cutting  dovvn  upon  it  or  subcu- 
taneously,  and  has  come  to  the  following  conclusions^  : — 
"  Nerve-stretching  has  an  influence  on  tabes,  which  is  due 
to  its  action  on  the  cord  itself,  as  shown  by  the  effects 
on  other  nerves  which  have  no  connection  with  the  one 
that  has  been  stretched.  Remote  effects  of  this  kind  take 
place  transversely,  as  well  as  longitudinally,  throughout 
the  cord.     They  are  partly  stimulating,  partly  paralysing, 

^  "  Tiber  Nervendehnung.  Eine  experimentelle  und  klinische  Studie.'* 
Leipzig,  1883. 
2  Loc.  cit.f  p.  166. 


THE  TREATMENT  OP  TABES  SPINALIS.  321 

and  are  shown  in  the  sphere  of  motion,  co-ordination, 
the  function  of  the  bladder  and  rectum,  the  secretory 
functions,  the  sensory  and  reflex  actions.  SensibiHty  is 
affected  in  all  its  different  forms,  viz.,  contact,  pres- 
sure, farado-cutaneous,  temperature,  and  pain.  The  most 
constant  result  is  the  relief  of  pain,  and  it  is  for  this  that 
the  operation  should  be  chiefly  performed  when  other 
means  have  failed,  more  especially  as  subcutaneous  stretch- 
ing of  the  sciatic  nerve  is  entirely  devoid  of  risk.  Should 
this  latter  operation,  however,  fail,  the  cutting  operation 
is  not  allowable  where,  in  consequence  of  loss  of  control 
over  the  bladder  and  bowels,  infection  of  the  wound  may 
be  feared." 

Stintzing's  statement,  that  subcutaneous  stretching  of 
the  sciatic  nerve  is  entirely  devoid  of  risk,  must,  however, 
not  be  taken  literally  ;  for  Baum  has  recorded  the  case  of 
a  young  man  who  died  of  collapse  during  that  operation. 
Inspection  showed  multiple  heemorrhages  along  the  sciatic 
nerve,  in  all  the  intervertebral  foramina,  and  in  the  dura 
and  pia  mater  up  to  the  cervical  portion  of  the  cord.  I 
have,  therefore,  arrived  at  the  opinion  that  nerve-stretching 
is,  under  any  circumstances ^  a  hazardous  operation  in  tabes; 
and  I  have  recently  ceased  to  recommend  it. 

A  few  words  must  be  said  about  some  other  remedies 
which  should  not  be  used  in  this  disease.  Of  these,  the 
principal  one  is  strychnia,  which  I  have  known  to  do  harm, 
whether  given  per  os  or  subcutaneously.  Counter-irritation 
of  the  spine  was  condemned  by  Romberg  more  than  forty 
years  ago,  when  hardly  ever  a  patient  came  to  consult  him 
whose  back  did  not  show  numerous  cicatrices  owins;  to  the 
seton,  the  actual  and  potential  cautery,  the  moxa,  and 
cupping.  While  in  Pott's  disease,  and  in  chronic  pachy- 
meningitis counter-irritation  to  the  spine  is  justifiable,  and 
not  unfrequently  followed  by  tolerably  good  results,  the 
same  treatment  applied  to  tabes  can  only  injure  by  the 
suffering  it  causes.     As  a  matter  of  fact,  the  only  form  of 

Y 


322  SCLEROSIS  OF  THE  SPINAL  CORD. 

counter-irritation  which  is  now  used  in  tabes,  more  espe- 
cially in  France,  is  the  "  pointes  de  feu "  by  means  of 
Paquelin's  gas-cautery ;  and  those  who  use  the  latter 
profess  to  do  so,  not  for  the  purpose  of  curing  the  disease, 
but  for  the  relief  of  pain. 

For  the  latter  we  have  a  number  of  other  remedies  which 
often  prove  useful.  Amongst  them  are  faradisation  of 
the  skin  ;  application  of  a  very  small  circular  anode  con- 
veying the  constant  current,  the  large  cathode  being  placed 
at  a  distance  from  the  affected  part ;  subcutaneous  injection 
of  plain  water  (p.  154),  and  of  morphia  and  atropia,  fol- 
lowed by  a  few  whiffs  of  ether ;  local  applications  of  a 
belladonna  and  chloroform  liniment,  of  aromatic  spirit  of 
ammonia,  and  of  ether-spray  ;  and  for  internal  use  the 
salicylate  of  soda  in  ten  or  twenty  grain  doses  ;  hydrate 
of  chloral ;  tincture  of  gelseminum  ;  and  bromide  of  ura- 
nium, in  pills  containing  one- seventieth  part  of  a  grain. 

For  optic  atrophy,  De  Wecker  has  recommended  stretch- 
ing of  the  optic  nerve  !  and  Kiimmell,  of  Hamburg,  has 
actually  performed  this  operation  in  three  cases,  in  one  of 
which  the  results  are  stated  to  have  been  good,  while  in 
the  other  two  they  were  negative.  G-alezowski  has 
recently  recommended  subcutaneous  injections  of  cyanide 
of  gold,  one-fourteenth  grain  as  a  dose  ;  while  subcuta- 
neous injection  of  strychnia  has  been  practised  for  years 
past  without  producing  much,  if  any,  effect.  As  I  have 
found  the  general  effects  of  strychnia  injurious  in  tabes, 
I  would  strongly  dissuade  practitioners  from  resorting 
to  this  drug  whether  for  optic  atrophy  or  other  symp- 
toms. 

Where  nocturnal  emissions  of  semen  are  troublesome, 
bromide  of  ammonium,  combined  with  hydrate  of  chloral 
and  tincture  of  lupulus,  proves  useful.  For  atony  of  the 
bowels  I  can  strongly  recommend  the  fluid  extract  of 
Cascara  Sagrada,  given  in  doses  of  from  ten  minims  to  a 
fluid  drachm,  once  or  twice  a  day.     For  nocturnal  inconti- 


THE  TREATMENT  OF  TABES  SPINALIS.  323 

nence  of  the  urine  a  piece  of  goldbeater's  skin  may  be 
placed  over  the  opening  of  the  urethra  and  fixed  with 
collodion  ;  and  in  catarrh  of  the  bladder,  with  ammoniacal 
decomposition  of  the  urine,  salicylate  of  soda  internally,  and 
washing  out  the  bladder  with  antiseptics,  are  useful. 


Y  2 


824:  SCLEROSIS  OF  THE  SPINAL  CORD. 


CHAPTER  X. 

FRIEDREICH'S  DISEASE. 

The  pathology  and  causes  of  this  form  of  sclerosis  have 
already  been  discussed  (pp.  65  and  112).  We  have  seen 
that  it  constitutes  a  diffuse  form  of  sclerosis  of  different 
portions  of  the  spinal  cord  and  medulla  oblongata,  which  is 
clinically  as  well  as  anatomically  distinct  from  tabes  and 
from  insular  sclerosis ;  and  that  it  tends  to  appear  in  several 
members  of  the  same  family  about  the  time  of  the  de- 
velopment of  puberty,  and  in  some  cases  even  at  an  earlier 
age. 

The  malady  generally  commences  without  any  apparent 
exciting  cause  or  premonitory  symptoms,  with  a  feeling  of 
muscular  debility  in  one  or  both  legs.  Walking  becomes 
difficult,  but  does  not  show  the  peculiar  features  of 
Duchenne's  ataxy.  The  gait  is  staggering,  like  that  of 
a  di'unken  person,  but  the  want  of  co-ordination  is  not  in- 
creased by  shutting  the  eyes.  After  a  time  the  trouble 
spreads  to  the  upper  extremities,  and  the  finer  movements 
of  the  hands  and  fingers  become  impossible.  The  affection 
assumes  occasionally  the  hemiplegic  form.  The  head  is 
sometimes  seen  to  oscillate  like  that  of  a  person  who  goes 
to  sleep  on  a  chair ;  and  this  tremor  is  increased  when  the 
patient  voluntarily  moves  his  head. 

There  is  also  a  peculiar  form  of  nystagmus,  showing 
want  of  synergy  in  the  muscles  of  the  eyeballs.  Fried- 
reich 1  and  Seeligmiiller  ^  have  found  this  to  be  one  of  the 

1  "  ArcMv  fiir  Psychiatrie,"  vol.  vii.,  p.  235.     1876. 

2  J^i(?.,  vol.  X.,  p.  222.     1879. 


Friedreich's  disease.  325 

later  symptoms  of  the  disease,  and  distinguished  from 
ordinary  nystagmus — such  as  is  seen  in  children  together 
with  opacities  of  the  cornea  and  lens,  or  strabismus,  in 
albinos,  etc. — by  its  non-occurrence  during  rest.  In  the 
usual  form  of  nystagmus  there  is  at  all  times  a  peculiar 
restless  oscillation  of  the  eyeballs,  generally  in  a  horizontal 
direction,  but  occasionally  rotatory ;  while  the  nystagmus 
of  Friedreich's  disease  only  appears  when  the  patient 
attempts  to  fix  his  eyes  on  an  object ;  and  its  direction  is 
then  either  horizontal,  vertical,  or  diagonal.  If  an  object 
be  moved  from  one  part  of  the  visual  field  to  another,  and 
the  patient  be  told  to  follow  it  with  his  eyes,  jerky  motions 
of  the  eyeballs  are  perceived,  which  clearly  show  ataxy  or 
asynergy,  being  irregular  in  character  and  much  slower 
than  those  of  ordinary  nystagmus.  Friedreich  considers 
this  nystagmus  to  be  owing  to  disease  of  the  nuclei  of  the 
ocular  muscles  on  the  floor  of  the  fourth  ventricle. 

After  a  time  the  speech  becomes  slow  and  drawling,  and 
eventually  quite  unintelligible.  The  tongue,  however,  ap- 
pears to  be  freely  movable  in  all  directions,  can  be  easily 
protruded,  and  held  out  without  any  appearance  of  tremor ; 
yet  in  the  later  stages  of  the  disease  there  may  be  tremor 
in  the  tongue  and  glossoplegia.  Towards  the  end  we 
observe  more  or  less  complete  muscular  paralysis  and 
atrophy,  and  occasionally  pain,  cramps,  and  rigidity. 

A  curious  feature  of  the  complaint  is,  that  sensibility  does 
not  suffer  until  the  very  last ;  while  in  ordinary  tabes 
lightning-pains,  areas  of  hypergesthesia  and  anaesthesia, 
numbness  in  the  soles  of  the  feet  and  the  sphere  of  the 
ulnar  nerve,  are  early  symptoms.  The  sphincters  do  not 
suffer,  and  there  is  for  a  long  time  no  tendency  to  bed- 
sores. The  cutaneous  reflex  sensibility  and  the  electric 
tests  are  normal.  The  tendon  reflexes  have  not  been 
studied  in  the  earlier  cases,  but,  where  they  were  investi- 
gated, were  found  to  be  absent.  The  intellect  is  normal, 
and  the  special  senses  do  not  suffer.     Argyll-Eobertson's 


326  SCLEROSIS  OP  THE  SPINAL  COED. 

symptom,  which  is  so  common  in  ordinary  tabes,  is  absent 
in  the  complaint  now  under  consideration.  In  men  there 
is  impotency ;  and  in  women  menstruation  is  irregular  and 
unsatisfactory.  Less  constant  symptoms  are  curvature  of 
the  spine  and  a  peculiar  form  of  vertigo,  which  comes  on 
in  paroxysms,  and  is  not  influenced  by  the  position  of  the 
patient  when  the  attack  begins. 

The  course  of  the  malady  is  exceedingly  slow  ;  and  it 
is  only  quite  towards  the  end  that  sensibility  becomes 
affected,  and  that  there  is  tendency  to  sacral  bed-sores  and 
catarrh  of  the  bladder,  with  pain  and  cramp  in  the  muscles. 
Symptoms  pointing  to  an  affection  of  the  medulla  ob- 
longata are  then  apt  to  make  their  appearance,  viz.,  acce- 
leration of  the  pulse,  excessive  perspiration  and  salivation? 
and  diabetes  insipidus.  Death  is  preceded  by  Cheyne- 
Stokes's  respiration.  In  one  case  the  affection  lasted 
altogether  thirty-one  years ;  in  another  twenty-six ;  and 
where  death  took  place  at  an  earlier  period,  it  was  owing 
to  typhoid  fever,  to  which  these  patients  seem  specially 
apt  to  succumb.  They  appear  to  possess  only  slight 
powers  of  resistance  to  the  typhoid  poison,  and  collapse 
is  apt  to  set  in  at  an  early  period  of  the  malady.  This 
was  in  some  cases  no  doubt  promoted  by  an  excessive 
fatty  degeneration  of  the  heart,  which  was  found  after 
death. 

From  what  we  have  said  it  will  be  apparent  that  the 
disease  is  as  different  from  ordinary  tabes  as  one  form 
of  Bright's  disease  from  another ;  indeed,  the  symptoms 
resemble  rather  more  those  of  insular  or  multiple  cerebro- 
spinal sclerosis  than  the  common  form  of  tabes.  Sclerosis 
in  patches  is  also  liable  to  become  developed  towards 
puberty ;  th.ere  is  no  sentient  or  sensory  trouble ;  the 
sphincters  act  well,  but  there  is  an  affection  of  speech 
and  vertigo.  On  the  other  hand,  the  peculiar  form  of 
tremor  which  is  seen  in  multiple  sclerosis  does  not  occur  in 
Friedreich's  disease ;    and  there  are  exaggerated  tendon- 


Friedreich's  disease.  327 

reflexes,    spastic  gait,   and  muscular   rigidity,    strabismus, 
diplopia,  aud  impaired  intellect,  in  multiple  sclerosis. 

The  diagnosis  of  Friedreich's  disease  can  therefore  rarely 
present  any  difficulties.  Its  prognosis  is  gloomy,  and  no 
kind  of  treatment  has  as  yet  appeared  to  be  able  to  arrest 
the  progress  of  the  malady,  much  less  to  improve  or 
cure  it- 


328  SCLEKOSIS  OF  THE  SPINAL  CORD. 


CHAPTER    XL 

SPASTIC  SPINAL  PAEALTSIS. 

The  patliology  of  spastic  spinal  paralysis,  or  spasmodic  tabes 
dorsalis  has  been  shown  (p.  51)  to  be  as  yet  in  a  most 
unsatisfactory  condition,  and  to  require  a  great  deal  of 
further  elucidation  by  careful  anatomical  investigations. 
Although  there  is  prima  facie  evidence  to  connect  this  dis- 
ease vrith  primary  sclerosis  of  the  lateral  columns,  and 
more  especially  of  that  portion  of  it  which  is  known  as 
the  crossed  pyramidal  strands  (p.  11),  yet  it  cannot  be  said 
that  this  has  been  convincingly  proved,  and  we  shall, 
therefore,  be  on  safe  ground  in  reserving  our  opinion  on 
the  actual  anatomical  base  of  this  malady. 

The  causes  of  the  complaint  are  somewhat  better  known. 
We  have  seen  that  eating  bread  mixed  with  the  meal  of 
lathyrus  cicera  will  give  rise  to  it  (p.  71),  not  only  in 
men,  but  also  in  horses  (p.  73)  ;  that  the  influence  of  the 
neurotic  constitution  is  much  more  marked  in  its  produc- 
tion than  in  that  of  tabes;  that  sex  and  age  appear  to 
have  very  little  influence;  and  that  a  syphilitic  history  is 
much  more  rarely  obtained  in  this  affection  than  in  tabes 
(p.  123). 

The  chief  symptoms  of  spastic  paralysis  appertain  to 
the  motor  sphere,  and  consist  of  loss  of  power  in  the 
limbs,  rigidity  and  spasm  of  the  muscles,  and  exaggeration 
of  the  tendon  reflexes.  The  paresis  or  paralysis  generally 
affects  at  first  either  one  or  both  lower  extremities,  and 
the  patient's  first  complaint  is,  therefore,  of  a  difficulty  in 
walking.    He  soon  gets  tired,  and  is  apt  to  drag  one  or 


SPASTIC  SPINAL  PARALYSIS.  329 

both  legs  on  the  ground.  Some  patients  feel  the  greatest 
difficulty  on  rising  in  the  morning,  and  improve  as  the  day 
advances.  The  legs  feel  heavy,  stiff,  and  weak  ;  the  loss 
of  power  gradually  becomes  more  marked,  and  eventually 
merges  into  paresis  and  complete  paralysis.  At  no  time, 
however,  is  there  any  ataxy  of  movements,  and  it  makes 
no  difference  to  the  patient  whether  he  stands  or  walks 
with  his  eyes  closed  or  open. 

I  have  found  it  most  useful,  in  my  examination  of  these 
cases,  to  measure  the  exact  degree  of  muscular  force  which 
may  be  present,  with  a  dynamometer  constructed  for  me 
by  Weiss  and  Son,  for  ascertaining  the  condition  of  mus- 
cular power  in  the  lower  extremities.  The  patient  puts 
his  foot  on  this  instrument,  first  in  the  sitting  position,  and 
presses  as  hard  as  he  can ;  the  excursion  of  the  index  is 
then  noted,  and  the  latter  replaced ;  he  then  gets  up  and 
puts  the  same  foot  on  the  instrument,  resting  the  entire 
weight  of  his  body  on  it ;  the  excursion  is  noted  again, 
and  the  proceeding  repeated  for  the  other  side.  I  find  the 
healthy  averages  to  be  as  follows: — 

Right  side,  sitting       140 

„  ,,      standing    ... 

Left  side,  sitting 
„       „     standing 

Now  in  spastic  paralysis  a  considerable  diminution  of 
these  numbers  is  obtained,  according  to  the  degree  of  loss 
of  power  which  may  be  present.  If  these  numbers  are 
entered  .each  time  the  patient  is  thus  examined,  an  objec- 
tive record  of  improvement  or  deterioration  will  be.  fur- 
nished. In  somewhat  advanced  cases  the  index  remains 
at  zero. 

The  use  of  this  instrument  is  also  valuable  for  diagnostic 
purposes.  My  colleague,  Hughes  Bennett,^  has  drawn  at- 
tention to  the  circumstance,  which  has  also  been  dwelt  upon 


160° 
130° 
140° 


1  (< 


Medical  Times  and  Gazette,"  Nov.  3,  1883. 


330  SCLEROSIS  OF  THE  SPINAL  CORD. 

by  Miiller,  of  G-ratz,  that  young  women  may  exhibit  all 
the  signs  of  primary  spastic  paralysis,  simulating  sclerosis, 
and  yet  eventually  recover.  In  some  such  cases  there  are 
indications  that  there  is  a  general  hysterical  condition,  but 
in  others  all  signs  of  hysteria  are  wanting.  Bennett 
laments  that  there  is  not  a  single  point  by  means  of  which 
we  are  enabled  to  differentiate  these  two  conditions, 
although  this  is  undoubtedly  of  great  practical  importance  ; 
for  many  unfortunate  women  suffering  from  spinal  disease 
are  considered  hysterical,  while  others,  who  by  a  vigorous 
regime  might  be  rapidly  cured,  are  incarcerated  for  life  as 
hopeless  invalids.  It  is  commonly  assumed  that  nothing  is 
easier  than  to  distinguish  a  functional  from  an  organic  lesion, 
while  in  reahty,  in  some  cases,  nothing  is  more  difficult. 
This  is  evidenced  by  the  fact  that  in  some  instances 
sclerosis  and  pseudo-sclerosis  have  only  been  distinguished 
on  the  post-mortem  table,  by  the  most  distinguished  physi- 
cians. It  is  therefore  important  to  know,  that  the  dynamo- 
meter which  I  have  had  constructed  for  measuring  the 
force  in  the  lower  extremities,  will,  at  least  in  a  certain 
number  of  cases,  enable  us  to  distinguish  between  the 
functional  and  the  structural  form  of  spastic  paralysis.  In 
the  former,  although  the  patient  may  be  unable  to  walk, 
the  dynamometer  often  indicates  a  considerable  degree  of 
muscular  power  ;  while  in  the  latter,  more  especially  where 
the  disease  is  somewhat  advanced,  the  index  of  the  instru- 
ment will  only  indicate  20°  or  30°,  in  place  of  140°  or  160°, 
and  occasionally  will  make  no  excursion  at  all. 

Symjjtojns  of  motor  invitation  are  superadded  to  the  loss  of 
power  at  an  early  period  of  the  complaint.  The  legs  are 
occasionally  jerked  about  suddenly,  especially  after  exer- 
tion and  in  bed  ;  or  there  is  a  peculiar  kind  of  tremor,  or 
trepidation,  which  goes  on  for  a  considerable  time,  begins 
generally  in  the  feet,  and  spreads  from  there  to  the  legs, 
thighs,  and  body.  If  the  patient  be  walking  or  standing 
at  the  time  when  this  tremor  commences,  he  occasionally 


SPASTIC  SPINAL  PARALYSIS.  331 

stamps  the  ground  with  such  force  as  to  shake  the  room  in 
which  he  is,  and  the  noise  may  be  heard  at  a  considerable 
distance.  Such  symptoms  appear  to  occur  spontaneously, 
but  are,  in  reality,  owing  to  reflex  irritation  ;  for  they  may 
be  caused  at  any  time  by  a  sudden  attempt  to  bend  the 
knee,  or  by  dorsal  flexion  of  the  foot.  As  soon  as  an  at- 
tempt at  voluntary  movement,  more  especially  of  the  body, 
pulls  and  stretches  the  tendons  ever  so  little,  this  kind  of 
tremor  is  produced  ;  and  it  may  be  arrested  by  plantar 
flexion  of  the  foot,  whereby  the  mechanical  irritation  is 
counteracted. 

At  the  same  time  a  peculiar  stiffness  and  rigidity  of  the 
muscular  substance  is  noticed.  This  is  at  first  quite  tem- 
porary, and  chiefly  noticed  in  walking,  or  when  the  legs 
are  examined  and  passive  movements  are  attempted ;  but 
after  a  time  it  becomes  more  permanent;  and  eventually 
complete  and  permanent  contractions,  more  especially  in 
extension,  are  produced.  When  the  patient  is  in  bed, 
the  legs  are  held  in  extension  and  adduction,  and  great 
difficulty  is  experienced  in  changing  their  position.  The 
adduction  of  the  legs  may  be  so  strong  that  the  knees 
can  hardly  be  separated;  at  the  same  time  the  hip-joints 
are  slightly  flexed,  and  the  legs  everted.  The  rigidity  is 
owing  to  reflectory  tension  of  the  muscles,  and  is,  more 
especially  in  the  beginning,  increased  by  the  weight  of  the 
legs  as  they  stand  on  the  ground,  or  by  the  least  active  or 
passive  movements  which  irritate  the  tendons.  When  the 
legs  are  well  supported,  so  that  any  irritation  of  tendons  is 
avoided,  the  rigidity  is  lessened. 

In  connexion  with  this  point  it  is  important  to  know 
that  the  muscular  stiffness  may  be  greatly  diminished  by 
placing  the  patient  in  a  warm  bath.  The  legs  are  then 
carried  by  the  water,  and  lose  a  portion  of  their  weight, 
so  that  the  pulling  and  stretching  of  tendons  which  is 
simply  owing  to  weight  is  more  or  less  avoided.  The 
legs  are  then  found  to  be  no  longer  fixed  in  extension,  and 


332  SCLEROSIS  OF  THE  SPINAL  CORD. 

passive  movements  are  comparatively  easy.  Percussion 
of  tendons  has,  however,  the  same  influence  in  the  water 
as  in  the  air.  It  is  only  the  irritation  of  tendons  caused  by 
weight  and  pulling  which  is  lessened,  and  indeed  remains 
lessened  for  some  time  after  the  bath.  Prolonged  warm 
baths  are  therefore  very  useful  in  the  treatment  of  this 
affection. 

The  combination  of  loss  of  power  and  rigidity  leads  to 
a  peculiar  kind  of  a  walk  which  has  been  first  described 
by  Erb  as  the  "  spastic  gait."  ^  The  feet  seem  to  be  tied 
to  the  ground,  which  they  scrape ;  and  any  slight  uneven- 
ness,  which  they  may  happen  to  encounter  on  it,  becomes 
a  great  impediment  to  progress.  When  the  patient  goes 
downhill,  he  appears  to  be  dragged  along  by  the  simple 
weight  of  his  body ;  he  is  obliged  to  hurry,  and  is  in  danger 
of  falling  with  his  face  forwards.  He  walks  habitually  on 
tiptoe,  with  the  heels  lifted  up,  by  contraction  of  the  gas- 
trocnemii ;  and  the  points  of  the  boots  are  therefore  worn 
off  sooner  than  the  soles  or  the  heels.  The  whole  body  is 
generally  lifted  with  each  step,  and  may  be  either  thrown 
backwards  or  forwards.  The  legs  are  too  much  adducted, 
and  can  only  be  separated  by  considerable  efforts  on  the 
part  of  the  pelvic  muscles  ;  and  it  may  be  easily  imagined 
that  a  walk  with  such  difficulties  is  exhausting  to  the  last 
degree. 

It  is  singular  that  patients  of  this  kind,  when  they  are 
hardly  able  to  crawl  along,  can  stand  without  an  effort  for 
almost  any  length  of  time.  A  gentleman  who  was  sent  to 
me  in  November,  1871,  by  Mr.  Maclaren,  and  in  whom  I 
have  had  the  opportunity  of  watching  the  gradual  evolution 
of  this  disease  during  the  last  thirteen  years,  related  to  me 
some  curious  instances  of  this.  On  one  occasion  when  his 
walking  was  already  very  bad,  he  went  to  the  Derby  and 
had  the  greatest  difficulty  to  walk  from  his  carriage  to  the 
stand  with  the   help  of  two  friends  ;  but,   once  there,  he 

*  "  Krankheiten  des  Kiickenmarks,"  vol.  i.,  p.  96.     Leipzig,  1878. 


SPASTIC  SPINAL  PARALYSIS.  333 

stood  for  five  hours  consecutively  and  watched  all  the 
races  without  any  fatigue.  The  next  few  days  he  thought 
that  he  walked  a  great  deal  better.  On  another  occasion,  in 
1872,  he  stood,  on  the  Thanksgiving  Day  for  the  recovery 
of  the  Prince  of  Wales,  in  an  open  shop  for  five  hours  con- 
secutively, watching  the  procession,  and  again  walked  much 
better  the  next  few  days.  It  then  occurred  to  him  to 
utilise  standing  for  the  treatment  of  his  complaint,  and  he 
went  shortly  afterwards  to  the  Gaiety  Theatre,  and  stood 
out  a  whole  performance  there.  This,  however,  did  not 
succeed  ;  for  he  felt  much  worse  afterwards^  which  he  ex- 
plained by  the  air  in  the  theatre  having  been  very  hot  and 
stuffy. 

After  a  time  which  may  extend  over  several  years,  the 
upper  extremities  are  likewise  affected.  Loss  of  power  is 
experienced  in  the  hands  ;  the  patient  has  a  difficulty  in 
taking  hold  of  objects,  in  writing,  in  carving,  in  dressing 
himself,  and  more  especially  in  buttoning  his  clothes.  He 
finds  it  diffi^cult  to  lift  the  arm,  and  to  bend  the  elbow. 
Stiffness  and  rigidity  of  the  muscles  is  likewise  not  long 
in  making  its  appearance,  and  affects  then  chiefly  the 
flexors  and  adductors.  The  fingers  are  more  or  less 
clenched  into  the  palm  of  the  hand,  the  wrist  is  pro- 
nated  and  flexed,  the  elbow  semi-flexed  or  extended,  and 
the  arms  are  adducted  to  the  sides  of  the  body.  Occa- 
sionally, however,  I  have  seen,  even  at  an  advanced  stage 
of  the  affection,  pure  paralysis  without  rigidity  in  the 
muscles  of  the  upper  extremities. 

The  disease  soon  afterwards  invades  the  sacro-lumbar 
and  abdominal  muscles,  causing  loss  of  power  and  rigidity 
in  them.  The  abdomen  is  hard  and  prominent,  and  sepa- 
rated from  the  base  of  the  thorax  by  a  deep  horizontal 
ridge.  Respiration  is  then  apt  to  become  difficult,  although 
at  this  time  there  may  be  no  affection  of  the  medulla  ob- 
longata. The  patient  can  no  longer  sit  up  in  bed,  and 
gradually  becomes  more  thoroughly  helpless. 


334  SCLEROSIS  OF  THE  SPINAL  CORD. 

Occasionally  the  disease  assumes  the  form  of  hemiplegia 
or  cervical  paraplegia,  so  that  first  one  leg  and  then  the 
arm  of  the  same  side  is  affected  ;  or  both  arms  are  first  in- 
vaded, and  the  lower  extremities  follow  suit  some  years 
afterwards. 

The  next   symptom  of    importance  which  we  have  to 
consider  is  the  exaggeration  of  the  deep  reflexes,  which  con- 
titutes    one    of   the    most    characteristic    features    of   the 
disease.     The  knee-jerk  is  more  particularly  exaggerated, 
so  that  the  slightest  touch  of  the  ligamentum  patellae  with 
the  finger  or  percussion  hammer  causes  the  leg  to  fly  for- 
wards.    Another  mode  of  eliciting  it  is  to  fix  the  patella 
and  push  it  down  suddenly,  when  clonic  convulsions  may  be 
produced.     Percussion  of  the  substance  of  the  quadriceps 
will  have  the  same  effect,  the  degree  of  the  response  being 
inversely  proportionate  to  the  distance  of  the  point  per- 
cussed from  the  patella.      It  is,  however,    not   only  the 
tendon  reflexes,  but  also  the  periosteal  reflexes  which  are 
increased ;    for    percussion    of    the  tibia,  more  especially 
its    internal  edge,    may   likewise   cause   the  knee-jerk    to 
appear.     This  is  an  interesting  circumstance,  as  it  speaks 
very  strongly  for  the  reflectory  and  against  the  mechanical 
theory  of  these  phenomena.     Indeed  it  seems  impossible  to 
assume  that  the  knee-jerk  thus  produced  could  be  owing  to 
a  propagation  of  a  mechanical  concussion  to  the  muscle, 
inasmuch  as  the  slightest  blow  struck  on  the  lower  end  of 
the  tibia,  which  could  not  have  any  effect  on  the  thigh,  will 
elicit  the  response,  while  powerful  blows  on  other  parts 
of  the  leg  have  no  influence  whatever  in  causing  any  con- 
traction of  the  quadriceps. 

Ankle-clonus,  which  is  also  called  "  foot-phenomenon  "  or 
induced  trepidation,  is  another  important  reflex,  and  must 
be  looked  upon  as  an  exaggeration  of  the  normal  reflex  of 
the  tendon  Achillis.  It  is  produced  by  suddenly  lifting  the 
toes  or,  better  still,  the  front  part  of  the  foot  with  one 
hand,  while  the  patient's  leg  is  supported  under  the  knee- 


SPASTIC  SPINAL  PARALYSIS.  335 

joint  with  the  other  hand.  We  then  observe  a  series  of 
rhythmic  muscular  movements  or  oscillations  of  the 
affected  leg,  which  go  on  for  a  time  varying  from  half  a 
minute  to  five  minutes  and  more.  In  advanced  cases  the 
irritation  crosses  over  to  the  other  side,  so  that  both  legs 
are  shaken  by  clonic  convulsions,  and  the  phenomenon  is 
then  called  "  spinal  epilepsy  " — a  most  unsuitable  term 
which  should  be  discontinued.  Brown-Sequard  has  stated 
that  ankle-clonus  may  be  at  once  arrested  by  passive 
plantar  flexion  of  the  big  toe  ;  but  such  is  not  the  case,  as 
it  is  only  arrested  if  plantar  flexion  of  the  foot  is  made. 
This  latter  proceeding  neutralises  the  mechanical  irritation 
of  the  tendon  Achillis,  and  therefore  arrests  its  conse- 
quences. The  big  toe  may  be  ever  so  much  flexed,  and  yet 
the  ankle-clonus  will  continue,  provided  plantar  flexion  of 
the  foot  is  avoided.  On  the  other  hand  we  find  that,  where 
the  gastrocnemii  are  much  contracted,  the  production  of 
ankle-clonus  may  be  rendered  difficult  or  impossible,  as  a 
certain  amount  of  relaxation  of  the  tendon  is  essential  for 
the  causation  of  the  phenomenon.  In  some  cases  percus- 
sion of  the  tendon  Achillis  will  be  found  more  eflEective  in 
producing  the  clonus  than  dorsal  flexion  of  the  foot. 

Further  tendon-reflexes  which  may  be  elicited  in  an 
exaggerated  form  in  the  lower  extremities  in  spastic 
paralysis  are  those  of  the  glutsei  and  the  adductors  of  the 
thighs,  produced  by  percussion  of  the  lumbar  spine  ;  and 
of  the  biceps  femoris,  the  semi-tendinosus  and  semi-mem- 
branosus,  and  the  anterior  and  posterior  tibiales,  by  per- 
cussing their  respective  tendons. 

In  the  upper  extremities,  likewise,  a  great  variety  of 
exaggerated  deep  reflexes  may  be  produced.  By  percuss- 
ing the  vertebrae  of  the  cervical  spine,  various  muscles  of 
the  arm  may  be  caused  to  contract ;  by  tapping  the  collar- 
bone, the  pectoralis  major  and  the  biceps  may  be  affected  ; 
and  by  percussion  of  the  lower  end  of  the  radius  and  ulna, 
and  of  the  bones  of  the  carpus  and  metacarpus,  reflexes  in 


336  SCLEROSIS  OF  THE  SPINAL  CORD. 

neighbouring  and  distant  muscles  may  be  elicited.  Crossed 
periosteal  reflexes  are  also  seen,  so  that  on  percussing  the 
collar-bone  of  one  side  a  contraction  occurs  in  the  biceps  of 
the  other  side.  Percussion  of  the  internal  condyle  of  the 
tibia  will  cause  the  adductors  of  the  thigh  to  contract 
powerfully  on  the  same  side,  and  rather  less  strongly  on  the 
opposite  side ;  and  a  tap  on  the  sternal  ends  of  the 
upper  ribs  may  cause  contraction  of  the  opposite  pectoralis 
major. 

In  some  cases  considerable  differences  are  noticed  in  the 
degree  of  exaggeration  of  the  deep  reflexes  on  the  two  sides, 
more  especially  with  the  patellar  reflex  ;  and  it  is  then 
generally  found  that  such  exaggeration  is  proportionate  to 
the  loss  of  power  in  the  limb.  In  a  patient  whom  I  saw 
with  Dr.  Mackintosh,  of  the  Brompton  Road,  in  April,  1882, 
ajid  in  whom  the  right  leg  was  worse  than  the  left,  the 
knee-jerk  was  much  more  violent  in  the  right  than  in  the 
left  side,  and  ankle-clonus  could  only  be  produced  in  the 
right,  but  not  in  the  left  foot. 

If  a  muscle  is  made  to  contract  by  percussing  its  tendon, 
the  same  may  be  brought  about  in  a  general  way  by 
directly  percussing  its  substance.  A  knowledge  of  the 
motor  points  of  the  muscles,  which  is  so  important  in 
carrying  out  faradisation,  is  useful,  as  it  is  chiefly  from 
these  points  that  such  contractions  may  be  elicited. 
Striimpell  ^  contends  that  such  a  contraction  is  frequently 
a  reflex  proceeding  from  the  fascia  of  the  muscle,  and 
may  then  affect  the  entire  belly  of  it  just  as  if  the 
tendon  had  been  percussed.  This  may  be  seen  in  the 
gastrocnemius,  but  more  especially  in  the  semi-membranosus 
and  semi-tendinosus  muscles;  and  the  fact  that  the  effect  is 
greater  by  percussing  the  upper  than  the  lower  portions  of 
the  muscle — that  is,  farther  away  from  the  tendon — 
appears  to  speak  against  the  phenomenon  being  owing  to 

^"Deutsclies  Archiv  fiir  klinische  Medicin,"  vol.  xxiv.,  p.  178. 
Leipzig,  1879. 


SPASTIC  SPINAL  PARALYSIS.  337 

mechanical  transmission  of  the  concussion  to  the  tendon. 
This,  however,  does  not  hold  good  for  all  cases ;  for  I  have 
already  remarked  that  in  spastic  paralysis  the  contractions 
produced  by  percussion  of  the  quadriceps  are  generally  all 
the  more  marked  the  nearer  the  blow  is  struck  to  the 
patella;  and  the  extent  of  the  projection  of  the  leg  is 
seen  to  become  less  and  less  in  proportion  as  the  blows 
fall  higher  up. 

The  response  to  percussion  of  tendons,  fasciae,  periosteum, 
and  muscles  has  appeared  to  me  to  differ  in  certain  par- 
ticulars according  to  the  nature  of  the  lesion  by  which  it  is 
produced;  and  when  this  part  of  our  subject  will  have 
been  thoroughly  worked  out,  I  am  convinced  that  it  will 
be  found  to  possess  considerable  diagnostic  importance. 

I  propose  to  distinguish  amongst  the  whole  class  of 
exaggerated  reflexes  : — 

1  St.  The  cerebral  type  ; 

2nd.  The  spinal  type  ;  and 

3rd.  The  muscular  type. 

Isfc.  The  cerebral  type  is  seen  where  sclerosis  of  the  cord 
is  consequent  upon  brain  lesions,  such  as  tumour,  soften- 
ing, haemorrhage,  and  similar  conditions.  The  response  is 
moderately  quick  and  very  extensive,  so  that,  taking  the 
patellar  reflex  as  an  example,  the  leg  is  thrown  forward  a 
considerable  way  up,  with  a  wide  swinging  motion,  and 
gradually  settles  down  again  after  some  considerable 
analogous  oscillations. 

2nd.  The  spinal  type  is  seen  in  spastic  spinal  paralysis, 
insular  sclerosis,  and  combined  system  diseases  of  the 
cord,  and  is  distinguished  by  an  exceedingly  quick  and 
jerky  motion  of  the  leg,  which,  however,  does  not  nearly 
cover  the  same  ground  as  the  reflex  of  cerebral  type.  The 
leg  is  jerked  forward  most  instantaneously  ;  indeed  if  one 
might  employ  a  Hibernicism,  1  would  say,  almost  before 
the  blow  is  struck;  and  the  after-oscillations  are  of  the 
same  short  and  jerky  character. 

z 


338  SCLEROSIS  OF  THE  SPINAL  CORD. 

3rd.  The  vscidartype  is  seen  in  local  morbid  conditions, 
such  as  peripheral  paralysis,  more  especially  of  the  portio 
dura.  The  muscular  contraction  which  is  then  observed 
is  very  analogous  to  that  which  is  seen  if  a  constant  cur- 
rent is  made  to  act  on  a  muscle  separated  as  far  as  possible 
from  all  nervous  elements.  We  perceive,  then,  not  a  quick 
jerk  of  the  muscular  fibres,  but  a  sort  of  sluggish  wave  in 
the  same,  which  begins  slowly,  lasts  some  time,  and  sub- 
sides slowly.  There  may  be  a  contraction  of  the  entire 
muscle,  but  the  contraction  is  generally  stronger  in  those 
fibres  which  are  directly  percussed. 

The  exaggerated  tendon  reflexes  may  be  still  further  in- 
creased by  the  administration  of  strychnia,  and  anything 
else  that  causes  an  exaltation  of  reflex  excitability  ;  while 
they  are  diminished  by  bromide  of  potassium,  and  anything 
which  has  a  tendency  to  subdue  that  faculty. 

It  is  generally  assumed  that  the  anatomical  cause  of  the 
exaggeration  of  the  deep  reflexes  is  to  be  found  in  sclerosis 
of  the  lateral  columns,  and  more  especially  in  that  portion 
of  these  columns  which  is  known  as  the  crossed  pyramidal 
strands  (p.  11).  This,  however,  is  by  no  means  proved. 
We  know  the  function  of  the  crossed  pyramidal  strands  to 
be  to  carry  the  orders  of  the  Rolandic  convolutions  to  the 
muscles  of  the  limbs,  and  we  should  therefore  rather  expect 
paralysis  to  be  a  symptom  of  their  destruction  than  exagge- 
rated reflexes.  The  latter  may  be  seen  in  cases  where 
there  is  certainly  no  disease  of  the  pyramidal  strands,  as, 
for  instance,  in  certain  forms  of  epilepsy,  in  acute  febrile 
complaints,  such  as  typhoid  fever,  in  consumption  and  other 
wasting  diseases.  We  cannot  explain  this  by  assuming 
the  existence  of  anaemia  of  the  cord,  as  we  find  that  in  the 
severer  forms  of  anaemia  the  deep  reflexes  are  not  exagge- 
rated. The  theory  that  the  reflex  excitability  of  the  cord 
is  unduly  increased  in  consequence  of  the  influence  of  the 
cortical  centres  being  removed,  is  also  unsatisfactory ;  for 
in  hemiplegia  after  cerebral  haemorrhage,  where  this  in- 


SPASTIC  SPINAL  PARALYSIS.  339 

fluence  is  certainly  removed,  we  find,  at  least  for  a  month 
after  the  attack,  that  the  deep  reflexes  are  not  exaggerated, 
while  the  superficial  ones  are  either  greatly  diminished,  or 
altogether  gone.  It  is  more  probable  that  there  are  pecu- 
liar connexions  of  different  spinal  reflectory  centres  with 
various  cerebral  reflectory  centres,  and  that  the  changes  in 
the  deep  reflexes  which  we  observe  are  owing  to  changes 
in  the  condition  and  the  relations  of  some  of  these  several 
centres  to  each  other  ;  but  the  exact  way  in  which  the  ex- 
aggeration of  the  deep  reflexes  is  brought  about  has  not 
yet  been  ascertained. 

We  occasionally  meet,  in  practice,  with  cases  which  have 
not  yet  been  classified,  where  there  is  no  paralysis,  but  such 
an  extraordinary  exaggeration  of  the  deep  reflexes,  that 
paralysis  is  simulated.  The  muscular  power  does  not 
suffer,  and  sensibility  is  normal  ;  yet  the  increase  of  the 
tendon  reflexes  is  such  as  to  impede  all  active  movements. 
The  patient  shows  all  the  characteristic  features  of  the 
spastic  gait,  with  this  difference — that  he  may  continue  to 
walk  for  hours  consecutively,  without  being  actually  ex- 
hausted. He  has  to  make  similar  efforts  to  those  of  a 
man  who  is  walking  in  deep  sand,  and  is  therefore  more 
easily  fatigued  than  a  healthy  person.  In  a  bath,  how- 
ever, he  may  move  about  without  any  trouble  at  all.  The 
rigidity  of  the  extensors  then  ceases,  and  his  legs  may  be 
flexed  with  ease. 

Sensibility  does  not  as  a  rule  suffer  in  spastic  spinal 
paralysis,  except  when  the  malady  is  very  far  advanced.  It 
is  true  that  in  the  beginning  of  the  complaint  the  patients 
occasionally  complain  of  shooting  erratic  pains  in  the  back 
and  legs,  but  these  rarely  reach  any  degree  of  severity, 
and  are  mostly  evanescent.  There  is  no  anaesthesia  or 
analgesia  either  in  the  skin  or  in  the  deef)er  parts.  The 
superficial  reflexes  are  generally  normal.  There  is  no 
muscular  atrophy,  the  faradic  and  galvanic  tests  are  fairly 
good,   and  there  is  no  trouble  on  the  part  of  the  pelvic 

z  2 


340  SCLEROSIS  OF  THE  SPINAL  CORD. 

organs.     The  urine  is  generally  normal,  but  occasionally 
contains  an  excess  of  urea  and  sugar. 

Case  77. — In  April,  1883,  Mr.  Bickersteth,  of  Liverpool, 
requested  me  to  see  an  unmarried  lady,  aged  twenty-one, 
who  had  for  several  years  past  uoticed  a  gradually  in- 
creasing weakness  in  her  legs,  which  had  rendered  her 
quite  helpless.  During  the  last  twelve  months,  how- 
ever, the  disease  did  not  appear  to  have  grown  much 
worse.  She  had  the  greatest  difficulty  in  lifting  her 
feet  off  the  ground,  to  which  they  seemed  to  cling, 
and  which  they  scraped.  Indeed,  the  gait  had  the 
true  spastic  character,  and  the  patient  could  only  make 
a  few  steps  when  supported  by  others,  or  when  sup- 
porting herself  by  taking  hold  of  the  wainscoting  or 
pieces  of  furniture.  There  was  no  muscular  atrophy,  but 
rigidity,  and  the  faradic  and  voltaic  excitability  of  the 
nerves  and  muscles  was  normal.  The  left  leg  appeared  to 
be  worse  than  the  right.  When  examined  with  the  dyna- 
mometer for  the  lower  extremities,  there  appeared  to  be 
such  loss  of  power  in  both  legs  that  the  patient  was  un- 
able to  move  the  index  at  all.  The  knee-jerk  was  greatly 
exaggerated  in  both  legs,  showing  spinal  type  (p.  337);  and 
ankle-clonus  could  be  readily  elicited.  Direct  percussion  of 
any  portion  of  the  quadriceps  caused  the  leg  to  be  thrown 
forward.  Passive  movements  caused  an  increase  in  the 
stiffness  of  the  muscles.  In  the  upper  extremities  the 
disease  was  not  nearly  so  far  advanced  as  in  the  lower. 
There  was  a  good  deal  of  muscular  force,  for  the  patient 
squeezed  the  ordinary  dynamometer  with  the  left  hand  to 
130°,  and  with  the  right  to  140°.  Both  hands,  however, 
were  shaky,  awkward,  and  stiff,  and  almost  useless  for  those 
finer  movements  which  are  constantly  required  in  daily  life. 
All  the  deep  reflexes  of  the  upper  extremities  were  in- 
creased, more  particularly  that  of  the  biceps,  and  the 
flexors  and  extensors  of  the  forearms,  as  well  as  of  the 
interosseous  muscles.     There  were  no  symptoms  whatever 


SPASTIC  SPINAL  PARALYSIS.  341 

of  hysteria,  and'  there  was  no  history  of  injury  or  severe 
exposure  to  cold.  Sensibility  was  normal  everywhere. 
Menstruation  and  the  action  of  the  bowels  were  reo"ular  : 
the  patient  slept  well  ;  but  the  urine  had  a  density  varying 
from  1032  to  1035,  and  contained  an  excess  of  urea  as 
well  as  of  sugar,  the  latter  amounting,  in  one  specimen,  to 
nearly  forty  grains  to  the  pint. 

Spastic  paralysis  is  mostly  a  very  chronic  affection, 
which  may  last  for  many  years  without  apparently  much 
tendency  to  shorten  life.  I  have  never  known  a  patient  to 
die  of  it.  Charcot  states  that  those-  suffering  from  this 
malady,  die  of  phthisis  and  other  affections  which  have  no 
immediate  connection  with  the  spinal  disease  ;  while  Erb 
has  seen  fatal  results  from  extension  of  the  disease  to  the 
medulla  oblongata,  and  from  blood-poisoning  owing  to 
cystitis  and  the  formation  of  bedsores.  Occasionally,  how- 
^ever,  the  course  of  the  disease  appears  to  be  more  rapid. 
Thus  Hopkins^  describes  the  case  of  a  porter,  aged  twenty- 
one,  who  found,  shortly  after  exposure  to  wet  and  cold,  his 
legs  becoming  very  weak  and  tottering.  After  some  months 
he  lost  the  feeling  in  the  soles  of  the  feet,  and  the  legs 
were  so  rigidly  flexed  that  they  could  not  be  passively  ex- 
tended. The  urine  became  alkaline  and  purulent,  bedsores 
formed  over  the  sacrum  and  the  trochanters,  the  upper  ex- 
tremities became  rigid,  the  temperature  began  to  rise,  and 
the  patient  died  two  years  after  the  commencement  of  the 
malady.  The  post-mortem  appearances  have  already  been 
described  (p.  52),  and  the  case  was  certainly  a  very  un- 
usual one. 

In  a  case  described  by  Cab  en,  the  patient,  when  apparently 
quite  well,  suddenly,  while  walking  in  the  street,  lost  the 
power  over  his  legs,  and  could  only  half  an  hour  after^vards 
crawl  along  to  a  wall,  where  he  remained  standing  for 
another  half -hour ;  after  that  he  could  walk  again  quite 
well.  Two  years  afterwards  he  had  pain  in  the  leg  for 
>  "Brain."     October   1883. 


342  SCLEROSIS  OP  THE  SPINAL  CORD. 

a  few  days,  and  involuntary  urination.  This  latter  dis- 
appeared in  a  week  ;  but  increasing  weakness  now  ap- 
peared in  the  legs,  with  tremor  and  rigidity.  Retention 
of  urine  supervened,  and  the  legs  became  gradually  so 
stiff  that  he  could  not  sit  up  in  bed ;  they  were  strongly 
adducted.  He  could  eventually  only  move  the  toes  a  little, 
having  lost  all  power  over  the  hips,  knees  and  ankles. 
The  patient  eventually  died  of  a  bedsore  which  had 
formed. 

In  the  further  course  of  the  complaint  sensibility  is  apt 
to  suffer  a  good  deal.  Schultz  mentions  the  case  of  a 
patient  who  had  lost  the  sense  of  temperature,  and  burnt 
himself  with  a  hot  bottle  without  knowing  it.  Sluggish- 
ness of,  and  eventually  total  loss  of  power  over,  the  bladder 
and  rectum  are  also  apt  to  come  on  after  a  time,  while  the 
sexual  desire  and  power  may  remain  unaltered  until  a  very 
late  period  of  the  illness. 

The  brain  and  cranial  nerves  are  generally  healthy.  I 
have,  however,  known  temporary  double  vision  to  occur  in 
the  beginning. 

^  T^  7^  y^  ^ 

The  diagnosis  of  spastic  paralysis  is  often  very  easy,  and 
sometimes  extremely  difficult,  more  especially  with  regard 
to  the  question  whether  there  is  a  decided  anatomical 
lesion  or  not.  This  difficulty  is  increased  by  the  circum- 
stance that  there  is  not  a  single  symptom  which  is  actually 
peculiar  to  the  disease ;  for  the  signs  of  motor  irritation 
which  I  have  described,  and  which  are  the  most  prominent 
feature  of  it,  may  occur  wherever  there  is  functional  irrita- 
tion or  structural  disease  of  the  pyramidal  strands,  from 
whatever  cause. 

It  is  hardly  possible  to  confound  the  disease  with  tabes, 
in  which  numerous  symptoms  in  the  sphere  of  sensibility 
are  to  be  found,  where  the  muscles  are  flabby,  and  where 
the  deep  reflexes  show  exactly  the  opposite  features  to 
what  we  see  in  spastic  paralysis. 


SPASTIC  SPINAL  PARALYSIS. 


343 


In  transverse  myelitis  from  compression  or  haemorrhage, 
the  symptoms  supervene  more  rapidly,  and  show  more  the 
purely  paralytic  character.  Rigidity,  if  it  occur  at  all, 
comes  on  at  a  later  period  of  the  disease.  Sensibility 
suffers  pari  passu  with  motility,  and  the  bladder,  rectum 
and  sexual  organs  are  afiected  at  an  early  stage. 

Cases  of  spastic  paralysis  which  assume  the  hemiplegic 
form,  will  scarcely  be  confounded  with  cerebral  hemiplegia. 
In  the  latter  the  symptoms  come  on  suddenly  ;  there  is 
frequently  loss  of  consciousness  and  speech ;  and  generally 
deviation  of  the  tongue  and  paresis  of  the  lower  branches 
of  the  portio  dura.  Moreover,  in  the  later  stage  of  cerebral 
hemiplegia  the  leg  is  almost  always  more  useful  than  the 
arm,  while  in  spastic  paralysis  the  leg  is  always  worse  than 
the  corresponding  arm. 

The  contractures  and  palsies  which  occur  occasionally  in 
hysteria,  do  not  in  general  resemble  those  which  we  see  in 
spastic  paralysis.  Hysterical  contractures  mostly  come  on 
suddenly,  over-night,  after  a  violent  emotion  or  a  convul- 
sive fit,  and  affect  only  one  group  of  muscles,  while  all 
others  are  left  intact.  Thus  the  flexor  muscles  of  the  fore- 
arm may  become  suddenly  contracted,  so  that  the  hand  is 
violently  clenched  and  pronated;  but  there  are  no  corres- 
ponding symptoms  in  the  other  arm,  or  in  the  legs.  More- 
over there  are  almost  invariably  other  signs  of  hysteria, 
such  as  a  highly  emotional  temperament,  a  worrying  dis- 
position, globus,  aphonia,  hemi-anaesthesia,  dysuria,  dys- 
menorrhoea,  pain  in  the  epigastrium,  which  is  increased  by 

pressure,  etc. 

The  aid  which  we  may  derive  from  the  dynamometei 
for  distinguishing  between  sclerosis  and  pseudo-sclerosis  ha& 
already  been  insisted  upon  (p.  329).  We  must,  however, 
remember  that  this  has  not  yet  been  shown  to  apply  to  all 
cases  of  pseudo-sclerosis,  as  in  some  of  them  the  symptoms 
appear  to  be  almost,  if  not  quite  identical  with  those  of 
actual  sclerosis.     These  cases  are  even  nowadays  not  un- 


344  SCLEROSIS  OF  THE  SPINAL  COED. 

frequently  called  hysterical,  although  there  may  not  be  a 
single  symptom  of  hysteria,  and  the  temperament  of  the 
patient  is  often  exactly  the  opposite  of  the  hysterical. 
Patients  of  this  kind  are  often  very-  calm,  intellectually 
gifted,  unemotional,  most  anxious  to  get  well,  and  have 
never  shown  such  symptoms  as  aphonia,  globus,  dysmenor- 
rhoea,  etc.  Even  the  further  course  of  the  disease  does 
not  invariably  lead  us  to  an  accurate  diagnosis,  for  although 
in  some  recovery  takes  place,  others  go  from  bad  to  worse, 
and  are  no  better  off  for  suffering  from  a  mere  functional 
derangement. 

Amyotrophic  lateral  sclerosis  is  distinguished  from  spastic 
paralysis  by  the  occurrence  of  muscular  atrophy  in  the  very 
commencement  of  the  complaint.  Moreover  the  former 
affection  is  more  rapid  in  its  course,  and  generally  affects 
the  upper  before  the  lower  extremities  ;  and  the  lesion  has 
the  tendency,  at  a  comparatively  early  stage,  to  creep  up 
to  the  medulla  oblongata. 

It  is  impossible  to  distinguish  insular  sclerosis  from 
spastic  paralysis  when  the  former  affects  only  the  lateral 
columns  of  the  cord.  In  general,  however,  certain  symp- 
toms on  the  part  of  the  brain  and  the  cranial  nerves 
will  be  discovered,  which  will  lead  us  on  the  right  track. 
These  are  chiefly  nystagmus,  a  slight  degree  of  optic 
atrophy,  drawling  speech,  vertigo,  and  failure  of  intellectual 
power. 

The  prognosis  of  spastic  paralysis  must  depend  upon 
the  anatomical  changes  which  may  be  present,  and  which 
it  is  not  always  possible  to  ascertain.  There  may  be 
chronic  myelitis,  multiple  sclerosis,  sclerosis  confined  at  one 
period  to  the  pyramidal  strands,  with  the  tendency  to  ex- 
tend later  in  life  to  the  anterior  cornua,  the  posterior 
columns,  etc.;  while  in  other  cases  there  is  nothing  but 
functional  irritation,  which  may  after  a  time  pass  off. 
Some  cases  have  completely  recovered  (Erb,  Van  der 
Velden,  Henck,  Schultz,  etc.),  but  this  is  exceptional  where 


SPASTIC  SPINAL  PARALYSIS.  345 

gross  anatomical  lesions  have  occurred.  In  general  the 
disease  is  apt  sooner  or  later  to  extend  to  other  portions  of 
the  nervous  system,  and  gradually  to  undermine  the  vital 
powers  of  the  patient. 

The  treatment  of  spastic  paralysis  has  to  vary  according 
to  the  cause  of  the  complaint.  Where  there  are  decided 
syphilitic  antecedents,  a  specific  treatment  should  be  re- 
sorted to,  on  the  same  lines  as  for  tabes  (p.  302).  On  the 
other  hand,  vfhere  the  sclerosis  appears  to  be  functional, 
more  especially  if  the  dynamometer  does  not  show  any 
actual  loss  of  power,  the  Weir-Mitchell  treatment  by 
massage  and  faradisation  may  prove  beneficial.  The  con- 
stant current,  administered  in  the  same  way  as  for  tabes 
(p.  310),  will  generally,  however,  be  found  the  best 
remedy.  Of  medicines,  I  have  found  a  combination  of 
arsenic,  in  doses  of  from  two  to  ten  minims  of  the 
liquor  arsenicalis,  and  bromide  of  potassium,  in  doses  of 
from  fifteen  to  thirty  grains,  thrice  daily,  the  most 
effectual.  Where  the  system  is  greatly  reduced,  phos- 
phorus, cod-liver  oil,  malt-extract,  and  the  generous  wines 
of  Burgundy  and  Hungary  should  be  administered.  Warm 
baths,  of  a  temperature  of  92°  to  100°,  should  also  be 
given,  either  daily  or  every  other  day.  The  temperature, 
as  well  as  the  duration  of  the  bath,  should  be  gradually 
increased,  in  accordance  with  individual  susceptibility. 
Warm  salt  or  sea  baths  answer  sometimes  better  than 
those  of  ordinary  water. 

Nerve-stretching  has  been  practised  in  this  country  and 
abroad  with  but  indifferent  results.  Southam,^  of  Man- 
chester, has  treated  a  case  which  was,  however,  somewhat , 
unusual,  by  stretching  of  the  left  sciatic  nerve-  There 
had  been,  apart  from  the  spasmodic  contraction  of  the 
muscles  and  the  exaggeration  of  the  tendon  reflexes, 
severe  pain  in  the  abdomen  and  lower  extremities,  which 
did  not  yield  to  morphia.  The  tendon  reflexes  and  the 
»  "The  Lancet,"  October  8,  1881. 


346  SCLEROSIS  OP  THE  SPINAL  CORD. 

muscular  rigidity  were  diminished  after  the  operation, 
and  the  pain  ceased  on  the  second  day,  and  had  not  re- 
turned six  weeks  afterwards.  The  tendon  reflexes,  how- 
ever, were  as  lively  as  ever  after  a  fortnight.  In  a  case 
reported  by  Westphal,  the  results  were  disastrous.  The 
extremities  became  completely  paralysed ;  there  was  loss 
of  control  over  the  bladder  and  rectum,  and  extensive  bed- 
sores formed,  which  it  took  years  to  heal.  The  operation 
therefore  appears  to  be  as  little  suitable  for  spastic  paralysis 
as  for  tabes. 


34: 


CHAPTER  XII. 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

This  form  of  sclerosis  was  first  described  by  Charcot,! 
and  although  it  resembles  in  many  respects  certain  cases 
of  ordinary  spastic  paralysis,  the  evolution  of  the  disease 
shows,  nevertheless,  such  peculiarities  as  to  warrant  us  to 
look  upon  it  as  one  sui  generis. 

We  have  seen  (p.  61)  that  amyotrophic  lateral  sclerosis 
has  for  its  anatomical  base  sclerosis  of  the  crossed  pyra- 
midal strands  and  of  the  ganglionic  cells  of  the  anterior 
grey  cornua  of  the  spinal  cord.  It  is  therefore  to  be 
looked  upon  as  a  combined  system-disease  of  that  organ. 
Its  causes  (p.  129)  are,  as  yet,  very  obscure. 

The  first  symptom  is  loss  of  power  in  the  upper  extremi- 
ties, more  particularly  in  the  hands  and  fingers,  and  fibril- 
lary twitches  in  the  affected  muscles,  such  as  we  see  them 
in  the  more  common  form  of  progressive  muscular  atrophy. 
"  Pins  and  needles  "  and  numbness  are  occasionally  felt  in 
the  arms.  Rigidity  and  contraction  supervene  after  a  time 
in  the  affected  muscles,  and  deformities  of  position  are 
noticed.  The  arm  is  firmly  drawn  towards  the  body,  the 
forearm  is  semi-fiexed  and  pronated,  and  the  hand  and 
fingers  are  strongly  clenched.  Passive  supination  and  ex- 
tension are  impossible  without  employing  an  undue  degree 
of  force  and  causing  pain.  The  tendon  reflexes  are  in- 
creased, but  there  is  no  anaesthesia  of  any  kind.  The 
electric  reactions  are  not  invariably  the  same,  as  in  some 

'  '*  Lemons  sur  les  Maladies  du  Systeme  Ntrveux."  2nd  Serie. 
Paris,  1874. 


348  SCLEROSIS  OF  THE  SPINAL  COED. 

cases  the  so-called  "  reaction  of  degeneration "  (Erb)  or 
wasting-test  is  noticed,  while  in  others  the  remaining  por- 
tion of  the  muscles  responds  normally  to  faradisation  as 
well  as  to  galvanisation. 

The  second  stage  of  the  disease  is  ushered  in,  about  six 
or  nine  months  after  the  beginning  of  the  first,  by  an 
analogous  affection  of  the  lower  extremities.  There  may 
also  be  "  pins  and  needles"  and  numbness  in  the  legs,  but 
the  principal  symptoms  are  again  loss  of  power,  twitches 
of  the  muscles,  with  rigidity  and  exaggerated  tendon  re- 
flexes. The  legs  are  rigidly  extended,  and  there  is  tremor 
on  attempting  movements.  After  a  time  the  muscles  be- 
come atrophied,  and  there  is  a  proportionate  decrease  of 
rigidity  and  reflex  excitability.  The  bladder  and  rec- 
tum continue  to  act  normally,  and  there  is  no  tendency  to 
bed-sores. 

The  third  stage  supervenes  more  or  less  rapidly  with 
symptoms  of  labio-glosso-laryngeal  paralysis  ;  the  patient 
becomes  unable  to  masticate,  to  swallow,  and  to  speak  ; 
respiration  and  circulation  eventually  suffer,  and  death  takes 
place  within  from  one  to  three  years  from  the  commence- 
ment of  the  disease. 

Ferrier^  has  reported  cases  in  which  the  medulla  ob- 
longata appeared  to  be  the  first  to  suffer,  and  where  the 
affection  subsequently  crept  down  to  the  upper  and  lower 
portions  of  the  cord.  Where  the  roots  of  the  spinal  acces- 
sory nerve  in  the  cervical  portion  of  the  cord  suffer,  there 
may  be  such  rigidity  in  the  trapezius  and  sterno-mastoid 
muscles  that  the  head  appears  completely  fixed.  In  such 
a  case,  in  which  I  was  consulted  in  April,  1884,  the  diag- 
nosis of  "  ossification  of  the  muscles  "  had  been  made  ! 
If  the  temporal  muscles  are  rigid,  from  the  sclerosis  affect- 
ing the  muscles  supplied  by  the  minor  portion  of  the  fifth 
nerve,  the  mouth  can  hardly  be  opened.  Occasionally  there 
is,  in  place  of  common  atrophy,  pseudo -hypertrophy  of  the 
1  ''The  Lancet,"  vol.  i.,  p.  822.     1881. 


AMYOTROPHIC  LATERAL  SCLEROSIS.  349 

affected  muscles,  which  may  render  the  recognition  of  the 
disease  difficult. 

The  diagnosis  of  amyotrophic  lateral  sclerosis  is,  how- 
ever, in  general  easy.  It  is  distinguished  from  spastic 
paralysis  by  its  much  more  rapid  course,  by  its  affecting 
generally  the  upper  extremities  previous  to  the  lower,  and 
by  being  accompanied  with  muscular  wasting  at  a  compara- 
tively early  stage.  Yfiih  progressive  muscular  atrophy  it  can 
hardly  be  confounded,  as  in  that  malady  loss  of  power  and 
muscular  wasting  proceed  pari  passu,  and  there  is  no  rigidity 
or  exaggerated  tendon  reflexes.  Where  bulbar  symptoms 
are  the  first  to  appear,  labio-glosso-phanjngeal  paralysis  may 
be  suspected,  but  the  speedy  supervention  of  signs  of 
motor  irritation  in  the  upper  and  lower  extremities  will 
generally  be  sufficient  to  lead  us  to  an  accurate  diagnosis. 

The  prognosis  of  amyotrophic  lateral  sclerosis  is  un- 
favourable, as  until  now  we  have  not  found  any  remedy 
which  seems  in  any  way  capable  of  arresting  the  rapid 
downward  course  of  the  disease.  The  constant  current 
and  prolonged  warm  baths  promise  more  than  any  other 
remedies. 


350  SCLEROSIS  OF  THE  SPINAL   COED 


CHAPTER  XIII. 

SECONDAET  LATEEAL  SCLEROSIS. 

This  form  of  sclerosis,  the  anatomical  features  of  which 
have  already  been  described  (p.  56),  is  owing  to  destructive 
lesions  of  the  motor  sphere  in  the  brain  or  spinal  cord, 
and  as  it  always  occurs  below  the  seat  of  the  anatomical 
lesion,  is  also  often  called  descending  lateral  sclerosis.  The 
part  affected  is  not  the  entire  lateral  column,  but  only  that 
portion  of  it  which  is  known  as  the  crossed  pyramidal 
column.  In  cerebral  lesions,  the  opposite  side,  and  in 
lesions  of  the  cord,  if  they  are  unilateral,  the  same  side,  is 
thus  affected. 

By  far  the  most  frequent  causes  of  secondary  lateral 
sclerosis  are  haemorrhage  in  the  central  ganglia  of  the 
brain,  and  embolism  or  thrombosis  of  the  middle  cerebral 
artery  and  its  branches.  If  haemorrhage  or  softening  in 
the  central  ganglia  be  very  limited  in  extent,  it  may 
partly  destroy  or  displace  the  grey  nuclei,  but  does  not  tear 
up  the  white  internal  capsule,  which  constitutes  the  great 
conducting  path  of  motor  power  from  the  brain  to  the 
limbs.  In  some  cases,  indeed,  the  pathological  lesion  is  so 
slight  that  there  are  hardly  any  symptoms  during  life ;  but 
where  the  lesion  is  somewhat  extensive,  crossed  incomplete 
hemiplegia  is  the  result,  which  is  generally  transitory,  for  the 
patient  mostly  recovers  the  power  over  the  affected  side  to  a 
great  extent  in  a  few  weeks  or  months.  In  such  cases  no 
secondary  or  descending  sclerosis  of  the  pyramidal  strands 
takes  place.  But  where  hemiplegia  remains  more  or  less 
permanent,  and  is  after  a  time  followed  by  late  rigidity  of 


SECONDARY  LATEEAL  SCLEROSIS.  351 

the  paralysed  muscles,  the  lesion  is  known  to  have  invaded 
that  portion  of  the  internal  capsule  which  contains  the 
pyramidal  strands,  thus  severing  the  connection  between 
the  psychomotor  centres  or  Rolandic  convolutions  and  the 
extremities.  ^ 

It  seems  at  first  sight  singular  that  disease  of  the  grey 
nuclei  should  cause  less  severe  symptoms  than  destruction 
of  white  matter,  which  does  not  generate,  but  only  conduct 
power.  This  fact,  however,  is  easily  understood  if  we 
consider  that  there  are  several  grey  centres,  and  only 
one  white  conducting  strand.  The  principle  of  com- 
pensation or  substitution  applies  to  the  several  grey 
nuclei.  Where  the  influence  of  the  lenticular  nucleus  is 
removed,  the  patient  may  fall  back  on  the  caudate  nucleus 
and  the  hemispheres,  and  will  after  a  time  be  found  not  to 
be  much  worse  oS  than  he  was  before  the  attack.  De- 
struction of  the  internal  capsule,  however,  creates  a  chasm 
between  all  the  grey  centres  generating  motor  influence,  on 
the  one  hand,  and  the  portio  dura  and  the  extremities  on 
the  other  hand,  which  cannot  be  bridged  over,  and  invari- 
ably leads  to  sclerosis  of  the  white  conducting  strands 
behind  the  lesion,  which  generally  becomes  developed  a 
month  or  two  after  the  stroke. 

The  following  symptoms  accompany  this  descending 
degeneration  : — About  a  month  or  six  weeks  after  the 
stroke,  there  is  a  feeling  of  stiffness,  which  differs  from  the 
powerless  feeling  of  the  first  few  weeks,  in  the  flexor 
muscles  of  the  paralysed  forearm,  and  these  gradually 
become  rigid.  The  fingers  are  clenched,  and  the  contrac- 
tion is  sometimes  so  extreme  that  the  nails  cut  into  the 
flesh.  The  thumb  is  flexed,  and  so  strongly  adducted  that 
it  disappears  under  the  other  fingers.  These  latter  offer 
great  resistance  to  an  attempt  to  open  the  hand  of  the 
patient.     The  forearm  is  pronated,  the  elbow  semi-flexed, 

'  Vide  my  Lecture,  "  On  the  Pathology  and  Treatment  of  Cerebral 
Paralysis."     "  British  Medical  Journal,"  June  4th  and  11th,  1882. 


352  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  the  arm  adducted  to  the  body.  A  degree  of  contrac- 
tion, however,  is  present  in  all  the  muscles — the  extensors 
and  abductors,  as  well  as  the  flexors  and  adductors,  and 
this  accounts  for  the  circumstance  that  it  is  sometimes 
difficult  to  make  any  considerable  change  in  the  position  of 
the  limb  by  passive  movements. 

In  the  lower  extremities  the  muscular  rigidity  is  gener- 
ally less  marked.  We  notice  it,  however,  in  the  hamstring 
muscles  of  the  thigh  and  the  flexors  of  the  leg  ;  and 
where  this  reaches  an  extreme  degree,  it  renders  walking 
quite  impossible,  as  the  leg  is  then  flexed  on  the  thigh,  and 
the  thigh  on  the  pelvis,  so  that  the  heels  touch  the  buttocks. 
If  the  extensors  and  adductors  of  the  leg  are  thus  affected, 
the  appearance  of  pes  equinus  is  caused.  The  patient  then 
walks  on  tiptoe,  and,  in  order  to  diminish  the  dragging  of 
the  foot  on  the  ground,  instinctively  swings  the  leg  from 
without  inwards,  which  constitutes  a  peculiarly  character- 
istic kind  of  gait. 

There  is  also  a  certain  amount  of  rigidity  in  the  face, 
which  is  more  particularly  noticed  when  the  patient  is 
talking,  laughing,  or  crying.  While  at  first,  when  there 
is  simple  palsy,  the  commissure  of  the  lips  is  depressed, 
it  becomes  later  on  raised  on  the  paralysed  side.  The 
naso-labial  sulcus  appears  more  marked ;  the  nostril  is 
dilated  ;  and  the  eye  looks  smaller,  from  rigidity  of  the 
orbicularis. 

Muscular  stiffness  is  greater  when  the  limbs  are  cold 
than  when  they  are  warm.  For  this  reason,  the  hand 
appears  more  open  when  the  patient  is  in  bed,  and  the  arm 
is  kept  under  the  bedclothes,  than  when  he  is  up.  It  is 
also  greater  in  the  waking  state  than  during  sleep  ;  and 
this  is  no  doubt  due  to  the  circumstance  that  emotions 
have  a  tendency  to  increase  it,  so  that  their  absence  during 
sleep  renders  the  contraction  less  marked.  The  rigidity  is 
also  exaggerated  by  efforts  to  use  the  paralysed  muscles  ; 
by  injuries,  such  as  a  blow  or  a  fall ;  by  faradisation  of  the 


SECONDARY  LATERAL  SCLEROSIS.  353 

skin  ;  by  the  old-fashioned  method  of  using  electro-mag- 
netism, which  consisted  of  making  the  patient  take  hold  of 
two  metallic  handles  with  both  hands,  and  thus  sendino-  a 
powerful  current  right  through  the  body.  Duchenne  has 
related  the  case  of  a  student  who  treated  himself  in  this 
fashion,  and  in  whom  the  exciting  effect  was  so  great  as 
to  cause  a  fresh  paralytic  attack.  The  administration  of 
strychnia,  which  was  formerly  much  in  vogue  for  the 
treatment  of  this  form  of  paralysis,  likewise  tends  to 
increase  the  rigidity  ;  and,  if  it  be  pushed  so  far  as  to 
cause  convulsive  movements  in  the  muscles,  they  are  more 
violent  in  the  paralysed  than  in  the  healthy  side.  Any- 
thing and  everything,  therefore,  which  has  in  a  general 
way  the  tendency  to  exaggerate  the  reflex  excitability 
of  the  cord  will  increase  the  rigidity  of  the  paralysed 
muscles. 

Late  rigidity  of  the  paralysed  muscles  after  hemiplegia 
was  formerly  believed  to  be  owing  to  inflammation  of 
the  brain  at  the  seat  of  the  lesion,  which  was  thought 
to  follow  habitually  upon  an  attack  of  apoplexy ;  but 
the  changes  which  really  follow  an  effusion  of  blood  are 
not  of  an  inflammatory  character.  Nor  is  it  due  to  the 
shrinking  of  the  cerebral  cicatrix,  as  Todd  believed  ;  nor 
to  peripheral  neuritis,  which  has  been  assumed  to  occur 
by  other  observers.  Neither  can  we  explain  it  by  an  in- 
crease of  reflex  excitability,  owing  to  the  removal  of  the 
inhibitory  influence  of  the  brain  ;  for  the  influence  of  the 
brain  upon  the  paralysed  Umbs  is  removed  immediately 
after  the  attack,  while  rigidity  only  comes  on  a  month  or 
two  afterwards. 

Pathological  anatomy  shows  as  the  only  constant  altera- 
tion in  these  cases  descending  sclerosis  of  the  crossed 
pyramidal  strands  ;  and  we,  therefore,  assume  that  this 
sclerosis  leads  to  irritation  in  the  large  motor  cells  of  the 
anterior  horns  of  the  spinal  cord,  and  thus  causes  that  con- 
tracted condition  of  the  muscles  which  is    in  reality   an 

A    A 


354  SCLEROSIS  OF  THE  SPINAL  CORD. 

exaggeration  of  their  normal  tonicity,  this  latter  being 
under  the  direct  influence  of  those  ganglionic  masses. 
Irritation  of  the  horns,  however,  is  a  very  different  thing 
from  actual  disease  or  destruction  of  them  ;  and  it  is  only 
in  exceptional  cases  of  cerebral  paralysis  that  these  horns 
become  really  diseased  in  the  further  coarse  of  the  affection. 
In  the  vast  majority  of  cases  there  is  no  muscular  wast- 
ing, except  what  may  be  accounted  for  by  disuse.  It  is 
indeed  singular  to  see  patients  who  have  been  deprived  of 
the  power  over  one  side  of  the  body  more  or  less  completely 
for  five  or  ten  years,  and  more,  and  in  whom  nevertheless 
the  muscular  tissue  is  fairly  nourished,  and  where  fara- 
disation causes  at  once  a  ready  response  by  inducing 
electro-muscular  contractions.  Compare  with  such  cases 
those  of  infantile  paralysis,  where  the  muscles  waste  away, 
and  lose  their  faradic  excitability  within  a  few  weeks, 
and  an  enormous  difference  is  at  once  seen,  which  is,  how- 
ever, satisfactorily  explained  by  the  anatomical  data  which 
I  have  just  given. 

In  some   cases,  however,  the  sclerosis  spreads    from  the 
lateral  column  to  the  anterior  horns  ;  and  we  then   notice  a 
corresponding  change  in  the   symptoms.     As  the  centre  of 
tonicity  is  gradually  being  destroyed,  the  rigidity  of  the 
muscles   diminishes  pari    passu,   and   ultimately   vanishes 
altogether.     When  the  muscles  become  more  relaxed,  the 
patient  is  apt  to  think  that  he  is  getting  better  ;  but  such 
hopes  are  delusive,  for  the  limbs  become,  on  the  contrary, 
more  feeble  as  time  goes  on,  and  the  muscles  are  found  to 
lose  their  faradic  excitability.     This  goes  on  much  in  the 
same   order  as  we  see  it  in  progressive  muscular   atrophy, 
affecting  first  the  muscles  of  the   shoulder  and  the  hand, 
and  afterwards  other  groups  of  muscles   in  succession.     It 
is  generally  protracted  over  two  or  three  years  ;  and  shoot- 
ing pains   are  often  felt  in  the  muscles  when  the  wasting 
commences.     All  grey  cells  being  connected,  the  degenera- 
tion may  spread  from  the  anterior  to  the  posterior  horns, 


SECONDARY  LATERAL  SCLEROSIS.  355 

or  to  the  anterior  horns  of  the  opposite  side  bj  means  of 
the  anterior  commissure  ;  and  we  have  then  no  longer  hemi- 
plegia, but  paraplegia  with  muscular  atrophy. 

It  is  doubtful  whether  cases  of  permanent  hemiplegia 
ever  exist  without  at  least  some  degree  of  rigidity.  This 
does  not  of  course  apply  to  lesions  of  the  grey  nuclei, 
where  the  internal  capsule  remains  unaffected  ;  for  in  these 
cases  the  paralysis  mends  so  much  soon  after  it  has  been 
established,  that  we  can  hardly  call  them  hemiplegic  two  or 
three  months  after  the  attack,  when  there  remains  simply 
a  degree  of  awkwardness  in  using  the  fingers,  but  no 
actual  paralysis.  The  patient  then  uses  his  Rolandic 
convolutions  where  formerly  he  used  the  lenticular  and 
caudate  nuclei ;  and  more  conscious  attention  and  trouble 
is  therefore  required  than  before  the  stroke.  Where,  how- 
ever, the  internal  capsule  has  been  injured,  and  the  affection 
is,  therefore,  more  severe,  there  is  probably  always  at  least 
some  degree  of  contraction,  which  is  sometimes,  indeed, 
barely  appreciable  when  the  limb  is  quiet,  but  which 
becomes  at  once  obvious  when  the  patient  is  requested  to 
make  an  effort,  however  slight.  Thus,  for  instance,  he  may 
be  able  to  move  his  arm  and  hand  in  all  directions  ;  but 
when  told  to  pick  up  a  pin,  or  to  unbutton  his  coat,  the 
fingers  and  hand  are  seen  to  contract,  rendering  such 
manipulations  difiicult  or  impossible.  On  examining  the 
state  of  reflex  excitability,  that  of  the  tendons  is  found  to 
be  exaggerated.  The  time  of  menstruation  in  women  is 
particularly  favourable  for  the  production  of  these  pheno- 
mena— no  doubt  owing  to  the  excitability  of  the  cord  being 
abnormally  high  during  that  period. 

The  prognosis  of  this  form  of  sclerosis  depends  upon 
the  amount  of  damage  done,  either  by  softening  or 
haemorrhage  in  the  brain.  Lesions  of  slight  extent  may 
be  more  easily  repaired  than  those  occupying  a  large  area. 
Age  and  constitution  of  the  patient  have  that  influence 
which  must  be  accorded  to  them  in  all  diseases ;  and,  finally, 

A  A  2 


^56  SCLEROSIS  OF  THE  SPINAL  CORD. 

much  depends  upon  tlie  treatment  which  is  adopted  at  an 
early  stage  of  the  malady,  and  chiefly  before  sclerosis  has 
heen  fully  established.  With  regard  to  this  point,  the 
occurrence  of  ankle-clonus  after  an  apoplectic  or  paralytic 
seizure  should  be  carefully  watched  for,  as  it  is  a  diagnostic 
sign  of  the  utmost  value,  leading  us  to  predict  the  probably 
speedy  appearance  of  late  rigidity  in  the  paralysed  muscles  ; 
and,  as  soon  as  that  symptom  has  made  its  appearance,  no 
time  should  be  lost  in  resorting  to  special  therapeutical 
measures. 

The  treatment  of  cerebral  paralysis  would,  prima  facie, 
appear  to  have  but  slight  chances,  as  in  one  class  of  cases 
there  is  a  natural  tendency  to  recovery  of  function  by 
compensation  of  allied  structures,  while  in  another  the 
destructiveness  of  the  lesion  and  its  consequences  would 
seem  to  render  all  therapeutical  efforts  futile.  The  ques- 
tion of  treatment  has,  therefore,  been  disregarded  by  many 
of  those  who  have  been  most  forward  to  investigate  the 
pathology  of  this  condition.  Nevertheless  this  must,  for 
all  time  to  come,  be  the  chief  point  of  interest  for  the 
practitioner.  No  doubt  some  cases  are  incurable  ;  yet  I 
think  I  shall  be  borne  out  by  those  most  conversant  with 
this  subject  when  I  say  that  few  cases  are  met  with  in 
T)ractice  which  may  not  be  improved  by  judicious  treat- 
ment. 

The  remedies  I  have  used  for  this  special  purpose  have 
been :  first,  phosphorus,  sometimes  simply  dissolved  in  a 
sufficiency  of  oil,  and  administered  in  a  capsule  or  perle 
twice  a  day,  in  doses  of  one-thirtieth  of  a  grain,  and  some- 
times in  cod-liver  oil,  where  the  general  state  of  the  patient 
seemed  to  render  the  latter  medicine  advisable  ;  and  second, 
the  constant  current,  sent  transversely  through  the  brain 
by  one  electrode  being  placed  to  the  right  and  the  other  to 
the  left  mastoid  process,  and  also  longitudinally  by  one 
being  placed  to  the  forehead  and  the  other  to  the  occiput. 
The  cathode,  which  is  the  more  stimulating  of  the  two  poles. 


SECONDARY  LATERAL  SCLEROSIS.  35T 

should  be  nearest  to  the  seat  of  the  lesion ;  so  that,  for  in- 
stance, in  right  hemiplegia,  the  cathode  is  placed  to  the  left, 
and  the  anode  to  the  right  mastoid  process.  Such  applica- 
tions are  made  daily,  the  current  being  allowed  to  pass  for 
from  five  to  ten  minutes  at  a  time.  Later  on,  local  appli- 
cations of  the  current  to  the  paralysed  parts  are  combined 
with  this.  These  latter  are  not  so  much  intended  to  act 
on  the  motor  nerves  and  muscles  as  on  the  sentient  nerves, 
by  which  the  stimulation  is  reflected  to  the  suffering  centre. 
Faradisation  is  also  sometimes  useful,  and  should  be  em- 
ployed to  the  antagonists  of  the  contracted  muscles. 

Our  second  object  should  be  to  counteract  the  sclerosis 
which  is  apt  to  follow  the  attack.  For  this  we  have 
several  remedies,  which,  if  used  at  a  sufficiently  early 
stage,  have  appeared  to  me  useful.  These  are  principally 
the  salts  of  gold  and  silver  and  ergot  of  rye.  Gold  is 
given  either  as  chloride  of  gold  or,  better  still,  as  chloride 
of  gold  and  potassium,  in  doses  of  one-eighth  to  one-half  a 
grain,  in  pills.  Silver  is  given  as  the  oxide,  nitrate  or 
phosphide,  in  doses  similar  to  those  of  gold.  Ergot  of  rye 
I  generally  give  in  the  form  of  the  liquid  extract,  in  doses 
of  from  half  a  drachm  to  a  drachm  three  times  a  day.  A 
good  plan  is  to  give  a  gold-salt  for  a  month,  a  silver-salt 
for  a  month,  and  ergot  for  a  month.  That  remedy  under 
which  most  improvement  appears  to  take  place  may  after- 
wards be  continued,  according  to  the  special  features  of  the 
case. 

Iodide  of  potassium  does  no  good  in  embolic  softening,, 
but  appears  useful  in  promoting  the  absorption  of  the  clot 
after  haemorrhage.  This  pathological  process  is  generally 
finished  in  about  six  weeks  after  the  attack,  and  it  is  rare 
to  see  much  good  resulting  from  that  remedy  at  a  later 
stage  of  the  disease.  Bromide  of  potassium,  on  the  other 
hand,  is  useful  when  reflex  excitability  appears  much  in- 
creased. 

A  word  must  be  said  about  the  employment  of  strychnia 


358  SCLEROSIS  OF  THE  SPINAL  CORD. 

in  these  cases.  This  is  a  remedy  for  paralysis  hallowed 
by  tradition  ;  yet  nothing  could  well  be  more  unphiloso- 
phical,  or  indeed  hurtful  to  our  patients  than  to  sanction 
or  to  continue  such  a  practice.  Strychnia  has  the  tendency 
to  increase  the  exalted  state  of  excitability  in  the  spinal 
cord,  and  thus  to  render  the  muscular  rigidity  worse.  It 
is,  therefore,  a  medicine  which  should  never,  on  any 
account,  be  given  in  such  cases. 

The  general  health  has,  of  course,  to  be  carefully 
attended  to  at  the  same  time.  We  must  remember  that 
some  patients,  viz.,  the  subjects  of  embolism,  suffer  from 
heart-disease  ;  while  others,  in  whom  the  attack  has  been 
owing  to  hsemorrhage,  are  probably  affected  with  small 
aneurisms  in  different  portions  of  the  brain,  which  may 
burst  subsequently,  and  give  rise  to  fresh  attacks.  Strain- 
ing at  stool  is  dangerous  for  such  persons,  and  the  action 
of  the  bowels  should  therefore  receive  great  attention* 
The  morale  of  the  patient  is  often  improved  by  change 
of  air  and  scene,  as  soon  as  he  is  sufficiently  well  to  bear  a 
journey.  We  cannot  expect  much  from  mineral  water 
cures  in  the  further  progress  of  these  cases.  Wildbad, 
Gastein,  Buxton,  and  other  spas  have  had  a  reputation  in 
the  treatment  of  cerebral  paralysis  and  secondary  sclerosis 
which  has,  however,  not  stood  the  test  of  time  and  strict 
criticism ;  and  it  is,  on  the  whole,  better  to  send  such 
patients  to  places  which  are  easily  accessible,  where  all 
comforts  can  be  procm-ed,  and  which  possess  well-known 
climatic  advantages.  A  moderately  dry  bracing  air  is 
found  to  be  particularly  suitable  for  these  patients  ;  but 
high  elevations  must  be  avoided. 


There  is  a  peculiar  form  of  secondary  sclerosis,  causing 
spastic  paralysis  in  children,  to  which  I  have  already 
alluded  (p.  57),  and  which  is  owing  to  disease  of,  or  defi- 
ciency in,  the  E-olandic  convolutions. 


SECONDARY  LATERAL  SCLEROSIS,  359 

Tlie  symptoms  of  this  form  of  sclerosis  point  to  the 
circumstanee  that  the  paralysis  is  primarily  dependent  on  a 
cerebral  lesion,  and  that  the  spinal  cord,  or  rather  the 
pyramidal  strands  "of  the  lateral  columns,  are  only  sub- 
sequently! affected. 

In  some  cases  there  is  original  malformation  of  the  skull, 
which  may  resemble  that  of  a    microcephalic   idiot  ;  and 
there  is  a  distinct   deficiency  of  cerebral  matter,  either  in 
one  or  both  hemispheres  (porencephaly).     In  other  cases, 
protracted  or  instrumental  delivery  is  the  cause.     The  head 
is    sometimes  so   much    squeezed   by    the   blades    of   the 
forceps  that  a  crushing  lesion   of  the  cerebral  substance  is 
produced,  which  is  followed  by  encephalitis  ;  or  there  is 
haemorrhage  in  the  cortex.      The  infant  is  then  seized  with 
convulsions  immediately  after  birth,  and  may  continue  con- 
vulsed for    some    days,    and  is    soon    after    discovered    to 
be  hemiplegic ;  or  it    is    seized   with   convulsions  a    few 
months  or  even  a  few   years   after  birth.     The  convulsive 
seizures  may  be  of  the  ordinary  epileptic  type,  viz.,  uncon- 
sciousness and  general  convulsions,  or  only  one-half  of  the 
body  may  appear  convulsed.      Sometimes  there  are  five  or 
six  such  fits,  and  the  child  is  afterwards  found  to  be  hemi- 
plegic.    The  hemiplegia  becomes  after  a  time  complicated 
with  late  rigidity,  and   occasionally  with  hemichorea   and 
athetosis.    The  development  of  the  paralysed  limbs  is  more 
or   less  arrested  ;    the   bones   are  seen  to   be  shorter  and 
smaller  than  those  of  the  healthy  side.     There  is,  however, 
no  muscular  wasting,  such  as   we   find  after  an  attack  of 
polio-myelitis  ;  and  the  faradic   and   voltaic  responses  are 
normal.     In   some   cases   there   is   no  actual  paralysis,  but 
paresis    and  great  awkwardness  in  the  use  of   the  limbs- 
The   tendon  reflexes   are  invariably  exaggerated  ;  and  the 
rigidity  of  the  muscles  is  sometimes  so  great  that  the  legs 
are  in    a   position  of   extreme    adduction    and   extension 
The  paralysis   is   either   hemiplegic  or  paraplegic,  and  if 
the  latter,  it  must  be  looked  upon  as  bi-hemiplegic  and 


360  SCLEROSIS  OF  THE  SPINAL  COED. 

cerebral.  Occasionally  wasting  of  the  rigid  muscles  super- 
venes, and  we  have  then  the  clinical  aspect  of  a  combined 
secondary  system  disease  of  the  cord. 

There  is  always  a  degree  of  mental  deficiency  in  such 
children  varying  from  dulness  and  stupidity  to  complete 
imbecility.  The  speech  is  drawling,  or  peculiar  in  other 
ways.  Children  of  this  kind  sometimes  use  words  and 
have  a  pronunciation  which  is  quite  their  own,  and  retain 
them,  if  they  survive,  for  the  rest  of  their  lives.  Some  do 
not  walk  at  all ;  others  begin  to  walk  when  they  are  six 
or  seven  years  old,  and  retain  throughout  life  a  peculiarity 
in  their  gait.  We  find  occasionally  nystagmus,  con- 
vergent strabismus,  inequality  of  the  pupils  and  protrusion 
of  the  eyeballs.  Convulsive  fits  may  come  on  again  at 
any  subsequent  pdriod. 

The  prognosis  of  spastic  paralysis  of  children  is  most 
gloomy.  Orthopaedic  surgeons  generally  treat  these 
patients  with  more  zeal  than  discretion,  by  cutting  ten- 
dons and  the  use  of  complicated  apparatus  ;  but  in  the 
majority  of  cases  such  interference  can  only  injure. 


Secondary  descending  sclerosis  after  certain  affections  of  the 
spinal  cord  is  so  overshadowed  by  the  symptoms  of  the  pri- 
mary disease  that  it  is  not  necessary  to  dwell  upon  it  in  detail. 
It  occurs  in  haemorrhage  from  injuries  and  after  crushing 
lesions  of  the  spinal  cord,  provided  the  patients  survive  long 
enough  for  secondary  degeneration  to  become  established. 
I  saw  a  case  of  this  latter  kind  (No.  78),  in  consultation 
with  Dr.  Giffard,  of  Egham,  on  December  5th,  1883.  It 
occurred  in  one  of  the  pupils  of  the  Royal  Engineering 
College  at  Cooper's  Hill,  in  consequence  of  an  accident 
while  playing  at  football,  on  November  29th,  when  the 
lad,  aged  nineteen,  was  thrown  heavily  on  his  back,  with 
the  result  of  becoming  immediately  completely  paralysed 
and    anaesthetic    from    the    waist    downwards,    but    not 


SECONDARY  LATERAL  SCLEROSIS,         361 

insensible.     There  was  complete  paralysis  of  the  bladder 
and   bowels,    and   a   moderate    degree    of   priapism.      He 
was    unable    to    change   the    position    of    his    body,   and 
there   was  also  paralysis   and  anaesthesia  of  the  forearms 
and    hands,  while  a  feeble  degree   of  motion  and    sensa- 
tion existed  in  the  arms  and  shonlders.     He  was  unable  to 
cough,  to  clear  his  throat,  to  sneeze,  or  blow  his  nose ;  but 
could   move  his   head  from  one  side  to  the  other,  and  had 
no  difficulty  in  speaking,  masticating,  and  swallowing,  and 
could  put  out  his  tongue.     I  found  on  examination  that  all 
the   superficial  and  deep  reflexes  of  the  limbs  and  body 
were  completely  lost.     This  rendered  it  evident  that  there 
was  a  crushing  lesion  of  the  cervical  portion  of  the  spinal 
cord,  and  that  the  grey  centre  of  it  had  been  most  gravely 
injured.       I  therefore    predicted   the  occurrence  of   rapid 
muscular    atrophy  in  the  paralysed  limbs,  supposing  the 
patient  were  to    survive   the   injury.     When   I  saw  him 
again   on   January    30th,    1884,    extreme  atrophy  of   the 
muscles  of  the  body  and  all  four  extremities  had  become 
established,  while   the  few  remaining   muscular  fibres  were 
in  a  state  of  iHgidity,  and   showed  increased  tendon-reflexes, 
showing   that    secondary    degeneration    of   the    pyramidal 
strands  of  both  sides  had  become  developed. 

Similar  appearances  are  noticed  in  acute  transverse 
myelitis  which  is  likewise  owing  to  injury,  and  in  which, 
if  the  patient  survives  sufficiently  long,  secondary  sclerosis 
below  the  seat  of  the  disease  is  apt  to  supervene. 


362  SCLEROSIS  OF  THE  SPINAL  COED. 


CHAPTER  XIV. 

SCLEEOSIS  OF  GOLL'S  COLUMNS. 

Secondary  sclerosis  of  Goll's  columns  is  almost  invariably 
one  of  the  later  lesions  of  tabes  and  of  transverse  myelitis. 
Primary  sclerosis  of  the  same  strands,  apart  from  any  other 
lesion,  appears  to  be  exceedingly  rare,  as  up  to  the  present 
time  only  three  such  cases  have  been  recorded,  viz.,  by 
Pierret,^  Ducastel,^  and  Gowers.^  The  symptoms  appear 
to  have  been  a  mixture  of  those  of  tabes  and  spastic  para- 
lysis ;  but  this  is  a  chapter  of  pathology  which  has  yet  to 
be  written. 

*  ''Archives  de  Physiologie,"  p.  74.     Paris,  1873. 

2  "  Gazette  Medicale  de  Paris,"  No.  4.     1874. 

3  "  The  Lancet,"  vol.  ii.,  p.  876.     1879. 


363 


CHAPTER  XV. 

MULTIPLE  OR  INSULAR  SCLEROSIS. 

We  have  seen  the  anatomical  features  of  multiple,  insular, 
or  disseminated  sclerosis,  or  sclerosis  in  patches,  to  consist 
of  multiplication  of  the  nuclei  and  proliferation  of  the  fibres 
of  the  neuroglia,  followed  by  degenerative  atrophy  of  nerve- 
tubes,  with  persistence  of  the  axis-cylinder  (p.  62).  Its 
causes  are  still  very  obscure,  and  no  age  or  sex  is  exempt 
from  it  (p.  127).  As  Charcot  was  the  first  to  distinguish 
this  form  of  sclerosis  as  a  separate  pathological  entity,  I 
have  elsewhere  ^  proposed  to  call  it  ''  Charcot's  disease." 

The  commencement  of  multiple  sclerosis  may  be  sudden, 
with  an  attack  of  apoplexy  or  epileptiform  seizures.  If  the 
former,  the  symptoms  may  be  almost  identical  with  those  of 
an  ordinary  attack  of  apoplexy  from  cerebral  hasmorrhage  ; 
that  is  to  say,  there  is  a  feeling  of  giddiness  and  confusion, 
with  noises  in  the  head  and  tingling  in  the  limbs,  which  is, 
after  a  variable  time,  followed  by  loss  of  consciousness  and 
coma  ;  the  pulse  is  accelerated  ;  the  temperature  may  rise 
to  103°  or  even  105°;  the  face  is  livid  and  swollen  ;  there 
may  be  involuntary  evacuation  of  the  urine  and  faeces  ;  and 
hemiplegia  is  discovered.  After  a  time,  however,  which 
varies  from  twelve  to  forty-eight  hours,  the  patient  begins 
to  rally  ;  he  slowly  regains  his  consciousness,  and  within  a 
few  days  likewise  the  power  over  his  side.  Such  attacks 
may  come  on  every  few  months,  with  the  same  result ; 
but  the  patient  may  die  in  one  of  them.  They  are  most 
probably  owing  to  ischa^mia  of  the  brain  from  vaso- 
'  "  Diseases  of  the  Nervous  System,"  p.  330.     London,  1877. 


364  SCLEROSIS  OF  THE  SPINAL  CORD. 

motor  spasm ;  for  in  fatal  cases  neither  congestion  nor  em- 
bolism nor  lisemorrhage  has  been  found  to  account  for  the 
symptoms,  while  old  lesions  in  the  medulla  oblongata ^ 
affecting  the  centre  of  vaso-motor  power,  have  generally 
been  discovered.  Sometimes  the  patient  does  not  recover 
completely  from  such  an  attack,  but  is  found  afterwards  to 
be  troubled  with  double  vision,  amblyopia,  nystagmus,  im- 
paired articulation,  and  other  symptoms  of  defective  cerebral 
nutrition.  The  patient  whose  case  (No.  51)  has  been  de- 
scribed on  p.  144  had  had  repeated  attacks  of  hemiplegia 
and  aphasia /o7'  Jive  years  consecutively  before  the  symp- 
toms of  multiple  sclerosis  of  the  cord  became  definitely 
established.  The  occurrence  of  such  attacks  always  raises 
a  strong  presumption  of  syphilis  being  at  the  bottom  of 
the  complaint. 

In  the  majority  of  cases,  however,  the  invasion  of  the 
disease  is  slow  and  insidious  ;  and  we  may,  as  in  tabes,  dis- 
tinguish three  several  stages  or  periods  which  may,  and 
generally  do,  merge  imperceptibly  into  one  another. 

In  the  first  period  the  symptoms  are  often  ill  defined. 
The  principal  complaint  of  the  patient  is  that  of  a  gradual 
loss  of  power  in  one  or  both  lower  extremities,  which  has 
the  tendency  to  become  aggravated  as  time  goes  on,  and  to 
spread  to  the  upper  extremities.  The  limbs  feel  heavy, 
are  difficult  to  move,  aud  spastic  gait  (p.  332)  is  common. 
Muscular  stiffness,  rigidity,  and  contractions  appear  occa- 
sionally at  a  somewhat  early  period  of  the  malady,  which 
is  therefore  apt  to  be  confounded  with  spastic  paralysis ; 
but  at  this  period  the  patient  is  still  able  to  go  about  and 
attend  to  his  avocations.  He  frequently,  however,  com- 
plains of  headache,  giddiness,  and  mental  depression;  the 
memory  is  impaired ;  there  is  great  indifference  to  the 
affairs  of  daily  life,  and  occasionally  melancholia,  with  re- 
fusal of  food.  Grandiose  delirium  and  other  symptoms 
of  general  paralysis  of  the  insane  have  been  observed. 

Where  the  patients  are  children,  we  notice  an  inequality 


MULTIPLE  OR  INSULAR  SCLEROSIS.  365 

in  their  temper,  and  a  degree  of  excitability  which  is  iin . 
usual.  There  is  often  immoderate  laughing  or  crjing  about 
nothing  at  all.  The  mind  appears  dull  and  clouded ;  the 
memory,  which  may  formerly  have  been  excellent,  becomes 
impaired ;  and  the  child  eventually  appears  imbecile.  In 
such  cases  we  have  no  doubt  to  do  with  sclerotic  patches 
in  the  cineritious  substance  of  the  hemispheres.  Convul- 
sions occasionally  usher  in  the  beginning  of  multiple  scle- 
rosis, as  of  so  many  other  infantile  complaints  ;  and  Bris- 
towe  has  seen  a  case  in  which  somnambulism  occurred. 

Symptoms  in  the  sphere  of   sensibility  are  on   the  whole 
rare.     Lightning-pains  are  generally  absent,  but  occur  now 
and  then  (Case  49,  p.  143),  as  well  as  parassthesia  of  dif- 
ferent kinds ;   and  there  may  even   be  circular  tightness  or 
belt-sensation,  plantar    ansesthesia,   and    numbness   in  the 
sphere  of  the  ulnar  nerve.     In  such  cases  ataxy  of  gait,  or 
a  gait  which  appears  to  be  a  mixture  of  ataxy  and  paresis 
(Case  48,  p.  142),  may  be  seen.     There  is  decided  loss  of 
power,  combined  with  jerked  movements  of  the  legs  and 
stamping  of  the  ground,  as  well  as  Romberg's    symptom ; 
so  that  the  resemblance  to   tabes  is   close.     In    such  cases 
we  assume  the  existence  of  sclerotic  patches  at  various 
levels  of  the  posterior  columns,  in  addition  to  those  which 
we  have  reason  to  suspect  in  the   antero-lateral  columns  ; 
yet  such  patches  have  occasionally  been  found  in  the  pos- 
terior columns  post  mortem,    where    there    had    been    no 
symptoms  in  the  sphere  of  sensibility  during  life.     Schiile  ^ 
explains  this  by  assuming  that  certain  portions  of  the  pos- 
terior columns  and  the  central  grey  matter  may  still  be  able 
to  conduct  sensitive   impressions,   even  after  considerable 
damage    to  other   portions    of   the   same   tracts   has   been 
done.     In  cases   of  combined  system-diseases  of  this  sort, 
the  symptoms  incline  towards  that  column  which  is  princi- 
pally affected.  Where,  for  instance,  patches  exist  through- 

'  "Deutschea  Archiv  fiir  klinisclie  Medicin,"  vol.  vii.,  p.  159,  and 
vol.  viii.,  p.  223. 


366  SCLEROSIS  OF  THE  SPINAL  CORD. 

out  the  extent  of  the  posterior  columns,  including  the  pos- 
terior root-zones  of  the  lumbar  enlargement,  there  will  be 
more  the  symptoms  of  tabes,  with  loss  of  deep  reflexes,  and 
flabby  muscles ;  while  if  the  whole  extent  of  the  lateral 
column  is  more  or  less  affected,  and  patches  exist  only  here 
and  there  in  the  posterior  columns,  we  shall  have  more  the 
symptoms  of  spastic  paralysis,  with  rigid  muscles  and  ex- 
aggeration of  the  deep  reflexes. 

The  most  peculiar  and  characteristic  symptom  at  this 
stage  of  multiple  sclerosis,  howe"vter,  is  a  peculiar  kind  of 
tremor,  which  Charcot  was  the  first  to  notice  and  to  describe. 
This  tremor  only  becomes  manifest  when  somewhat  exten- 
sive purposive  or  intentional  movements  are  made,  and 
ceases  completely  during  rest.  Restricted  movements  are 
possible  without  tremor  ;  or  the  shaking  is  so  slight  that 
it  can  only  be  distinguished  in  such  acts  as  writing,  where, 
even  in  the  beginning  of  the  disease,  no  plain  and  bold 
strokes  are  possible,  but  where  there  is  in  almost  every 
letter  that  is  written  an  evidence  of  slight  unsteadiness, 
as  if  the  person  who  was  writing  were  under  the  in- 
fluence of  drink. 

Sclerotic  tremor  has  the  peculiarity  of  being  rhythmic 
in  character,  there  being  a  succession  of  muscular  con- 
tractions occurring  at  more  or  less  regular  intervals,  and 
keeping,  on  the  whole,  tolerably  close  to  the  direction  which 
it  is  intended  to  follow.  The  keener  the  intention  to  carry 
out  a  certain  movement,  and  the  closer  the  attention  given 
to  the  performance,  the  greater  is  the  tremor.  On  this 
account,  the  patient  has  generally  less  difiiculty  when  he 
is  alone  and  unobserved,  than  when  examined  by  a  doctor. 
If  the  patient  be  requested  to  put  out  his  tongue,  that 
organ  is  jerked  forward  suddenly  and  withdrawn  again,  and 
is  seen  to  work  about  either  in  or  out  of  the  mouth,  together 
with  tremor  in  the  labial  and  other  facial  muscles.  Similar 
shakings  are  seen  when  the  patient  is  asked  to  move  his 
arms  or  legs,  or  to  sit  up  or  stand  up,  and  more  especially 


MULTIPLE  OR  INSULAR  SCLEROSIS.  367 

when  complex  movements  are  attempted.  The  tremor  fre- 
quently affects  other  parts  than  those  which  happen  to  be 
active ;  so  that  when  the  arm  is  moved,  the  head  and  body 
begin  to  shake  ;  and  if  the  patient  is  requested  to  walk, 
no  part  appears  quiet,  but  he  is  shaking  all  over. 

Sclerotic  tremor  interferes,  therefore,  more  especially 
with  all  the  ordinary  useful  complex  movements  of  daily 
life.  The  patient  is  unable  to  take  a  cup  of  tea  without 
spilling  it  ;  he  has  the  greatest  difficulty  in  dressing,  shav- 
ing, buttoning  his  clothes,  in  carving  a  joint  or  cutting  his 
meat,  in  writing,  playing  the  piano,  etc.  The  character 
of  the  handwriting,  more  especially,  becomes  completely 
altered,  and,  after  a  time,  anything  that  the  patient  may 
attempt  to  write,  is  quite  illegible. 

The  tremor  is  generally  more  pronounced  in  the  limbs 
than  in  the  body  ;  but  I  have  seen  a  case,  which  I  believe 
to  be  unique,  where  sclerotic  tremor  affected  the  muscles  of 
the  body  exclusively  without  any  others. 

Case  79. — This  was  the  case  of  a  girl,  aged  25,  who  had 
been  pronounced  to  suffer  from  hysteria,  but  in  whom  not 
a  single  symptom  of  hysteria  existed  when  I  examined 
her.  The  girl  was  of  an  exceptionally  calm  and  un- 
emotional temperament,  and  deeply  regretted  being  disabled 
by  her  affliction  from  supporting  her  parents,  who  were  old 
and  infirm.  She  showed  no  symptoms  whatever  which 
could  have  been  referred  to  sclerotic  patches  in  the  pons, 
medulla  oblongata,  or  other  portions  of  the  brain  ;  spoke  in 
a  perfectly  natural  manner,  could  protrude  her  tongue  with- 
out jerking  it  about,  and  had  no  nystagmus.  She  could  use 
her  hands  for  work.,  writing,  doing  her  hair,  etc.,  and  had 
no  difficulty  in  moving  her  legs  in  bed.  As  soon,  however, 
as  she  attempted  to  rise  from  the  horizontal  position,  which 
she  had  habitually  assumed  for  the  last  six  months,  sclerotic 
tremor  of  such  a  violent  character  commenced  in  all  the 
muscles  of  the  body  as  to  render  all  efforts  for  getting  up 
unavailable.     The  body  of  the  girl  was  then  swayed  back- 


368  SCLEROSIS  OF  THE  SPINAL  CORD. 

-wards  and  forwards  in  the'  most  extraordinary  manner,  the 
jerks  being  short  and  sudden,  and  succeeding  each  other 
rapidly.  Respiration  became  panting,  and  the  pulse  ac- 
celerated, but  the  muscles  of  the  head  and  the  limbs  did 
not  participate  in  the  tremor.  This  same  kind  of  tremor 
also  occurred  when  her  attendant  attempted  to  shift  her 
position  ;  and  it  was  of  such  a  distressing  character,  that 
the  patient  preferred  remaining  for  many  hours  consecu- 
tively in  exactly  the  same  position  to  being  shifted,  in  spite 
of  the  discomfort  entailed  upon  her  by  her  fixed  attitude. 
All  the  deep  reflexes  were  exaggerated  ;  but  there  were  no 
other  symptoms  whatever,  either  in  the  sphere  of  sensi- 
bility or  elsewhere.  In  this  case  the  anatomical  lesion 
must  have  consisted  of  sclerotic  patches  confined  to  the 
antero-lateral  columns  of  the  entire  dorsal  and  the  lower 
cervical  and  upper  lumbar  portion  of  the  cord. 

From  this  description  it  will  be  seen  that  sclerotic  tremor 
and  the  tremor  of  paralysis  agitans  are  of  an  entirely 
different  nature.  In  shaking  palsy,  or  Parkinson's  disease, 
the  tremor  occurs  chiefly  during  rest.  If  the  hand  of  the 
patient  be  laid  on  a  table  near  which  he  is  sitting,  or  on  his 
thigh,  rhythmic  oscillations  are  observed,  which  go  on  inces- 
santly at  a  steady  rate,  generally  between  eighty  and  a 
hundred  in  the  minute,  as  long  as  the  hand  remains  in  the 
same  position  ;  but  if  the  patient  moves  his  hand  or  arm, 
or  takes  hold  of  an  object,  the  tremor  ceases  for  the  time 
being  altogether.  These  peculiarities  are  in  most  cases  so 
well  marked,  that  no  difficulty  can  arise  in  distinguishing 
the  tremor  of  shaking  palsy  from  that  of  multiple  sclerosis. 
There  are,  however,  exceptional  instances,  in  which  the 
symptoms  are  so  mixed,  or  apparently  muddled  up,  that 
there  is  a  difficulty  in  deciding  to  which  disease  the  tremor 
belongs. 

Again,  the  movements  of  chorea  in  no  way  resemble 
sclerotic  tremor.  In  chorea  the  movements  are  disorderly 
and   without  purpose,   and   occur  during  rest  as  well  as 


MULTIPLE  OR  INSULAR  SCLEROSIS.  369 

motion.  The  utter  absence  of  intention  is  their  chief 
characteristic  feature.  Thus,  when  a  patient  affected  with 
chorea  carries  a  cup  of  tea  to  his  mouth,  we  notice  move- 
ments of  an  entirely  contradictory  character,  which  have 
the  tendency  to  counteract  rather  than  to  assist  the  intended 
movement ;  while  in  multiple  sclerosis  the  intended  direc- 
tion of  the  movement  persists  in  spite  of  the  impediments 
which  are  occasioned  by  the  tremor. 

In  the  ataxic  and  terminal  stages  of  tabes  spinalis  we 
notice  movements  devoid  of  co-ordination,  which  in  a 
measure  may  resemble  choreic  and  sclerotic  movements  ; 
but  there  is  in  them  no  real  tremor  or  oscillations,  and  they 
are  at  fault  rather  by  being  too  abrupt  and  extensive,  and 
therefore  devoid  of  order.  The  ataxic  movements  again 
are  distinguished  from  choreic  and  Parkinsonian,  by  not 
occurring  during  rest,  but  only  when  movements  are  at- 
tempted. The  want  of  co-ordination  in  the  tabid  is  more- 
over always  increased  when  he  closes  the  eyes. 

Charcot  has  explained  the  sclerotic  tremor  by  assuming 
that  in  these  patients  the  nervous  influence  is  only  trans- 
mitted by  the  axis-cylinder,  which  is  deprived  of  its 
medullary  sheath,  so  that  there  is  no  continuous  action, 
but  jerky  and  irregular  oscillations.  This  view,  how- 
ever, appears  somewhat  too  mechanical  ;  and  most  ob- 
servers are  now  inclined  to  believe  that  the  tremor  is  rather 
owing  to  localisation  of  the  sclerosis  in  certain  parts  above 
the  medulla  oblongata  and  the  pons  Varolii,  as  it  appears 
to  be  absent  where  the  patches  are  confined  to  the  cord, 
and,  on  the  contrary,  present  where  areas  of  sclerosis  are 
found  in  the  central  ganglia  and  other  portions  of  the  brain 
without  simultaneous  disease  of  the  cord.  The  matter, 
however,  is  still  very  obscure  ;  and  Bastian^  has  recently 
recorded  a  case  in  which  the  tremor  was  absent  from 
first  to  last,   and   where   the   autopsy    showed   numerous 

'  "  Clinical    Society's  Proceedings,"    "  British    Medical    Journal," 
Oct.  20,  1883. 

B  B 


370  SCLEROSIS  OF  THE  SPINAL  CORD. 

patches  in  the  pons  and  medulla  oblongata,  one  of  them 
being  a  quarter  of  an  inch  in  diameter,  while  others  varied  in 
size  from  that  of  a  pea  to  a  mustard-seed.  The  white  sub- 
stance of  both  hemispheres  also  showed  small  grey  areas, 
none  of  which,  however,  implicated  the  grey  substance  of 
the  cortex.  Patches  were  also  found  on  the  surface  and 
through  different  parts  of  the  interior  of  both  thalami,  while 
the  corpora  striata  and  the  cerebellum  were  free  of  them. 
The  cord  showed,  after  straining,  small  areas  of  degeneration 
in  different  portions  of  the  lateral  and  posterior  columns  and 
the  contiguous  grey  matter.  Bastian  has  suggested  that 
the  absence  of  tremor  in  his  case  may  have  been  owing 
to  there  having  been,  at  an  early  period,  considerable 
degeneration  in  the  anterior  pyramids,  cutting  off  the  cere- 
bral influence  from  below ;  but  this  explanation  appears 
far  from  satisfactory.  It  is  true  that  there  was  an  early 
affection  of  the  medulla  oblongata,  as  shown  by  the 
presence  of  drawling  speech  ;  but  at  this  time  the  cerebral 
influence  was  by  no  means  cut  off,  since  the  patient  was 
still  able  to  walk  and  stand,  and  to  use  his  hands.  While 
therefore  variations  in  localisation  are  probably  the  cause 
of  either  absence  or  presence  of  tremor,  the  exact  spot 
which  is  of  influence  in  the  production  of  this  symptom 
has  not  yet  been  determined. 

Striimpell  has  suggested  that  the  tremor  of  multiple 
sclerosis  is  owing  to  a  pulling  and  stretching  of  tendons, 
which  takes  place  as  soon  as  a  sudden  or  energetic  move- 
ment is  attempted,  and  that  this  causes  reflex  movements 
in  the  muscles  corresponding  to  those  tendons  which  inter- 
fere with  the  proper  execution  of  the  intended  movement. 
If,  for  instance,  the  forearm  be  quickly  flexed,  there  will  be 
a  contraction  in  the  triceps,  causing  the  forearm  to  be 
stretched  for  a  short  time,  and  thus  the  intended  movement 
Avill  appear  irregular  and  tremulous.  This  explanation, 
however,  appears  likewise  unsatisfactory;  for  if  we  were  to 
accept  it,  we  should  expect  to  find  sclerotic  tremor  even  more 


MULTIPLE  OR  INSULAR  SCLEROSIS.  37l 

marked  in  spastic  paralysis,  where,  however,  the  tremor  or 
trepidation  which  is  seen  is  of  an  entirely  different  character. 

A  peculiar  form  of  vertigo  is  frequently  observed.  All 
objects  seem  to  the  patient  to  be  spinning  round,  and  he  him- 
self with  them  ;  so  that  in  order  to  save  himself,  he  takes  hold 
of  anything  near  him.  Th^s  giddiness  is  apt  to  come  on  in 
attacks  of  variable  duration,  and  must  not  be  confounded 
with  vertigo  of  an  entirely  different  character  which  occurs 
through  paralysis  of  one  or  several  of  the  ocular  muscles 
and  consequent  double  vision.  The  latter  may  be  at 
once  arrested  by  closing  the  affected  eye. 

Drawling  speech  is  very  common,  and  may  be  the 
first  symptom  of  the  illness  (Case  42,  p.  127)  ;  articulation 
is  slow  and  hesitating ;  one  syllable  is  pronounced  after  the 
other  in  a  sort  of  rhythmic  manner,  making  the  delivery 
exceedingly  monotonous.  Occasionally  even  one  syllable 
is  drawn  out  to  an  enormous  length,  so  that  the  patient 
does  not  say  "  yes,"  but  '^y-e-e-e-e-es."  At  the  same 
time  there  is  no  modulation  in  the  voice,  the  pitch  of  which 
is  somewhat  high,  and  remains  exactly  the  same  throughout 
a  conversation.  After  a  time,  however,  the  speech  becomes 
so  indistinct  as  to  be  unintelligible  to  a  stranger.  The 
difficulty  is,  however,  always  of  the  anarthric  rather  than 
of  the  aphasic  type,  as  the  jDatient  seems  never  to  be  at  a 
loss  for  words  to  express  himself,  and  is  able  to  finish  his 
sentence  without  difficulties  on  that  score.  The  impair- 
ment of  articulation  is  presently  followed  by  other 
symptoms  showing  an  affection  of  the  medulla  oblongata, 
viz.,  dribbling  of  saliva  from  one  or  both  corners  of  the 
mouth,  great  trouble  in  mastication  and  deglutition,  and 
feeble  phonation.  The  tongue  may  at  this  time  be  still 
freely  movable,  but  often  shows  fibrillary  twitches. 

Where  multiple  sclerosis  occurs  in  children,  their  speech 
is  generally  incomprehensible  from  the  first. 

Affections   of  the  ocular  muscles  are  by  no  means  un 
common.     There  may  be  convergent  strabismus,  nystag- 

p,  p,  2 


372  SCLEROSIS  OF  THE  SPINAL  CORD. 

mils,  or  ptosis  ;  and  some  of  these  symptoms  may  be  the 
first  to  attract  attention  : — 

Case  80. — In  October,  1880,  Mr.  Power  requested  me  to 
see  a  gentleman,  aged  twenty-nine,  single,  who  had  had 
syphilis  in  1872  ;  and  in  May,  1879,  was  troubled  with 
double  vision,  owing  to  paralysis  of  the  rectus  internus  of 
the  left  eye.  He  underwent  treatment  at  home  by  iodide 
of  potassium,  iron,  and  strychnia  without  any  effect,  and 
then  went  to  Aix-la-Chapelle,  where  he  had  a  large  number 
of  inunctions,  together  with  applications  of  the  constant  and 
induced  current.  In  spite  of  this  treatment,  however,  the 
disease  of  the  third  nerve  gradually  progressed  so  as  to 
develop  into  an  incomplete  form  of  ophthalmoplegia. 
When  I  saw  him,  there  was  ptosis  of  the  left  eyelid  ; 
almost  complete  paralysis  of  the  left  rectus  internus,  and 
paresis  of  the  rectus  superior.  The  eye  could  not  be 
brought  into  the  inner  corner,  but  could  be  slightly  moved 
upwards,  although  not  nearly  to  the  same  extent  as  the 
other  one.  The  pupil  was  enlarged,  and  did  not  constrict 
by  ordinary  daylight,  although  it  contracted  sluggishly 
when  a  burning  match  was  approached  to  the  eye.  There 
was  no  affection  of  the  bowels,  bladder,  and  sexual  organs. 
The  knee-jerk  was  found  to  be  greatly  exaggerated  on 
both  sides.  I  saw  the  patient  again  in  May,  1884,  when 
paresis  of  the  bladder,  with  tendency  to  ammoniacal  de- 
composition of  the  urine,  impotency,  and  difficulty  in  walk- 
ing had  become  developed,  and  there  was  slight  sclerotic 
tremor  in  the  upper  extremities,  with  exaggeration  of  deep 
reflexes.  The  muscles  of  the  lower  extremities  were 
extremely  thin  and  flabby,  as  is  seen  in  tabes,  but  without 
evidence  of  actual  pathological  wasting,  as  after  polio- 
myelitis, or  rigidity,  as  in  spastic  paralysis. 

Nystagmus  is  sometimes  an  early,  and  at  other  times  a 
late,  symptom.  In  some  cases  there  are  two  or  three 
oscillations  of  the  eyes  in  a  second,  while  in  others  there 
are  only  a  few  oscillations  every  five  or  ten  seconds.     It  is, 


MULTIPLE  OR  INSULAR  SCLEROSIS.  373 

on  the  whole,  more  noticeable  when  the  patient  fixes  his 
eyes  on  an  object  which  is  moving  ;  and  it  has  appeared  to 
me  to  partake  often  of  the  character  of  sclerotic  tremor. 

Amblyopia,  with  limitation  of  the  visual  field,  and 
Daltonism,  are  important  symptoms  in  multiple  sclerosis, 
more  especially  when  combined  with  decided  ophthalmo- 
scopic changes. 

Case  81. — In  November,  1880,  Dr.  Andrew,  of  Shrews- 
bury, requested  me  to  see  a  single  lady,  aged  twenty-six, 
who  had  for  about  eleven  years  suffered  from  loss  of  power 
which  commenced  very  insidiously  in  the  right  leg.  After 
a  time  the  left  leg  was  also  affected,  so  that  she  had  great 
difficulty  in  walking  ;  and  the  disease  then  gradually  crept 
upwards,  invading  the  upper  extremities.  Both  hands  are 
now  very  useless,  the  right  more  so  than  the  left.  The 
squeezing  power,  as  measured  by  the  dynamometer,  is  only 
30°  for  the  right  and  45°  for  the  left  hand.  There  is  no 
sclerotic  tremor,  but  the  deep  reflexes  are  considerably  ex- 
aggerated, while  the  superficial  ones  are  absent.  There  is 
no  muscular  rigidity  or  contraction  anywhere  ;  the  muscles 
are  flabby  and  thin,  but  not  pathologically  wasted,  and  re- 
spond well  to  galvanisation  and  faradisation.  The  knee- 
jerk  is  exaggerated,  and  more  so  in  the  right  than  in  the 
left  side.  The  patient  has  never  had  any  pain,  and  there 
is  not  a  single  symptom  in  the  sphere  of  sensibility.  She 
has  had  attacks  of  incontinence  of  urine.  The  left  optic 
disc  is  white,  and  the  arteries  are  small.  There  is  dimness 
of  sight,  and  temporal  limitation  of  the  field  of  vision 
on  that  side.  Both  pupils  are  large.  No  cause  of  the 
affection  could  be  ascertained. 

In  this  case  the  diagnosis  could  not  be  doubtful.  It  was 
evidently  not  a  case  of  tabes,  as  the  patellar  reflexes  were 
exaggerated,  and  sensation  was  normal  everywhere  ;  nor 
one  of  spastic  spinal  paralysis,  as  the  muscles  were  flabby 
instead  of  rigid,  and  no  contracture  existed  anywhere  ;  nor 
one  of  hysteria,  as  the  degree  of  exaggeration  of  tlie  deep 


374  SCLEROSIS  OF  THE   SPINAL  CORD. 

reflexes  varied  in  different  parts  ;  while  pain  or  tender 
spots  of  any  kind  had  been  absent  thronghout  the  illness, 
and  ophthalmoscopic  changes  existed. 

Amblyopia,  more  especially  if  connected  with  ophthalmo- 
scopic changes,  may  occasionally  enable  us  to  distinguish 
multiple  sclerosis  from  hysteria  or  pseudo-sclerosis. 
Gnauk  ^  has  examined  this  point  in  fifty  cases  of  undoubted 
multiple  sclerosis,  in  most  of  which  the  diagnosis  was  con- 
firmed  by  inspection  ;  and  found,  independently  of  palsies 
of  ocular  muscles,  inequality  of  pupils,  etc.,  in  twenty-eight 
cases  failure  of  sight :  in  eight  of  these  there  was  simple 
amblyopia  ;  in  five  others,  diminished  activity  of  vision  and 
limitation  of  the  visual  field  ;  and  in  fifteen,  changes  in 
the  fundus  oculi.  The  limitation  of  the  field  of  vision 
was  generally  temporal.  Amongst  the  changes  in  the 
fundus  as  seen  with  the  ophthalmoscope,  there  was  total 
optic  atrophy  in  two  cases,  partial  atrophy  in  ten,  and 
fresh  optic  neuritis  in  three.  Optic  atrophy  may  be  an 
initial  phenomenon  of  multiple  sclerosis,  and  may  precede 
the  evolution  of  other  symptoms  of  the  disease  for  years  ; 
and  there  may  be  no  apparent  proportion  between  the 
ophthalmoscopic  appearances  and  the  subjective  symptoms 
complained  of  by  the  patient. 

While  in  tabes  amblyopia  generally  merges  into  amau- 
rosis, with  complete  atrophy  of  the  optic  nerves  and  total 
blindness,  the  amblyopia  of  multiple  sclerosis  is  not  nearly 
so  progressive  in  character,  and  often  remains  stationary  for 
years.  This  is,  according  to  Charcot,  owing  to  the  degene- 
ration being  more  interstitial  than  parenchymatous,  and  to 
the  persistence  of  the  axis-cylinder  in  the  optic  nerve- 
tubes. 

Symptoms   on   the  part  of  the  other  nerves   of   special 

sense  are  likewise  not  uncommon.     In  the  patient  whose 

case   (No.    48)  has  been    described   on  p.    142,   the  first 

symptoms  of  illness  were  loss  of  taste  and  double  vision, 

1  "  Centralblatt  fiir  Nervenheilkunde."     June  1,  1884. 


MULTIPLE  OR  INSULAR  SCLEROSIS.  375 

whicli  proved  temporary  in  character.     In  the    following 
case  there  was  anosmia  and  deafness: — 

Case  82. — A  clerk,  aged  thirty-four,  married  and  father 
of  one  child,  was  sent  to  me  by  Dr.  Hill,  jof  Abbey  Road,  in 
March,  1884.  Sixteen  years  ago  he  had  had  a  severe  attack 
of  rheumatic  fever,  which  left  great  Aveakness  and  a 
cardiac  affection.  He  was  obliged  to  be  away  from  busi- 
ness altogether  for  twelve  months.  vSome  time  afterwards 
he  began  to  suffer  from  dyspepsia  and  severe  attacks  of 
vomiting  ;  he  sometimes  vomited  incessantly  for  a  whole 
day,  but  eventually  got  better.  In  December,  1882,  how- 
ever, he  had  a  return  of  the  vomiting,  and  suffered  from 
haemorrhage  from  the  mouth,  passed  blood  with  his  urine, 
and  had  purpura  stains  on  his  skin.  At  present  he  com- 
plains of  impaired  memory,  confused  feeling  in  his  head, 
and  startings  in  his  sleep.  About  three  months  ago  he 
found  that  he  had  lost  his  sexual  power.  The  bowels  at 
the  same  time  became  confined,  and  occasionally  do  not 
act  for  four  or  five  days ;  the  bladder  is  sluggish.  He 
has  habitually  to  wait  five  minutes  before  he  can  pass  any 
water  ;  then  it  comes  drop  by  drop,  and  the  performance 
takes  altogether  another  ten  minutes.  He  has  a  feeling  of 
tightness  across  his  chest  ;  has  occasionally  had  slight 
shooting  pains  in  the  legs ;  has  slight  numbness  in  the 
feet,  staggers  on  closing  his  eyes ;  cannot  stand  well  on  one 
leg,  or  go  downstairs,  and  is  very  unsteady  in  walking.  He 
has,  however,  lately  walked  as  much  as  eight  to  ten  miles 
on  a  stretch.  The  knee-jerk  is  greatly  exaggerated  in  the 
right,  and  normal  in  the  left  leg.  There  is  no  ankle- 
clonus,  and  the  excitability  of  the  quadriceps  is  not  in- 
creased. His  hands  are  shaky,  and  he  has  difficulty  in 
writing.  There  is  some  degree  of  ptosis  in  the  left  eye;  he  is 
completely  deaf  in  the  left  ear,  where  he  hears  neither  tuning- 
fork  nor  watch,  and  has  lost  the  smell  in  the  left  nostril; 
while  there  no  ophthalmoscopic  or  other  sign  of  optic 
atrophy. 


376  SCLEROSIS  OP  THE  SPINAL  CORD. 

This  patient  recovered  almost  completely,  under  the  in- 
fluence of  iodide  of  potassium  and  nitrate  of  silver,  in  about 
four  months  ;  and  it  is  therefore  possible  that  the  case 
may  have  been  not  one  of  multiple  but  of  "pseudo- 
sclerosis."    (  Vide  Chapter  XVI.) 

The  deep  reflexes  may  be  increased,  lost  or  normal ;  and 
this  depends  entirely  upon  the  localisation  of  the  morbid 
process.  Where  patches  occur  in  the  lumbar  portion  of 
Burdach's  columns,  the  reflexes  are  lost ;  vt^hile  if  this  be 
spared,  and  the  lateral  columns  are  chiefly  affected,  ex- 
aggeration of  the  patellar  and  other  deep  reflexes  must  be 
the  result.  The  latter  is  by  far  the  most  common  occur- 
rence. 

The  bladder  suffers  in  many  cases  of  multiple  sclerosis. 
In  Case  81,  p.  373,  there  had  been  incontinence ;  in 
Case  80,  p.  372,  paresis  with  ammoniacal  decomposition 
of  the  urine ;  in  Case  82  extreme  sluggishness  of  the  ex- 
pulsive power  of  the  bladder ;  in  Case  50,  p.  144,  great  irrita- 
bility of  the  viscus,  so  that  the  patient  felt  constant  desire 
to  pass  his  water,  and  wetted  the  bed  in  his  sleep.  In 
other  cases,  however,  where  localisation  is  different,  no 
symptoms  on  the  part  of  the  bladder  may  be  observed  for 
years. 

The  howels  are  frequently  confined,  and  the  sexual 
power  is  often  lost  (Case  80,  p.  372).  In  a  case  which 
was  under  my  care  some  years  ago,  difficulties  of  menstrua- 
tion were  one  of  the  first  symptoms  of  the  illness  : — 

Case  83. — A  single  lady,  aged  twenty-eight,  consulted 
me  in  January,  1877.  Her  illness  commenced  about  three 
years  ago,  with  double  vision,  which,  however,  went  off 
again  after  a  few  months.  In  that  year  the  period  became 
irregular,  apparently  without  any  cause,  as  she  missed 
it  twice.  The  year  after  that  she  only  had  it  twice  alto- 
gether, viz.,  in  May  and  November ;  and  now  it  is 
entirely  gone.  Two  years  ago  her  sight  became  much 
weaker  ;  and  at  present    there    is  some   degree    of    optic 


MULTIPLE  OR  INSULAR  SCLEROSIS.  377 

atrophy,  temporal  limitation  of  the  visual  field,  dimness  of 
sight,  and  djschromatopsia.  There  is  numbness  in  the 
little  and  ring  finger  of  the  left  hand,  but  no  actual  loss 
of  power.  She  complains  of  a  feeling  of  tightness  round 
the  chest.  Her  walk  is  uncertain ;  she  staggers  very 
much,  cannot  readily  put  her  foot  on  a  chair,  or  stand  on 
one  leg  without  support ;  nor  can  she  separate  the  feet 
when  they  are  close  together.  She  sways  to  and  fro  on 
closing  her  eyes.  The  bladder  is  atonic  ;  she  habitually 
goes  twelve  hours  without  passing  water,  and  then  only  does 
it  because  she  thinks  it  right  to  do  so.  When  she  wants 
to  pass  it,  she  has  to  wait  about  ten  minutes,  and  strain 
all  the  time  as  hard  as  possible,  and  is  then  about  ten 
minutes  longer  in  passing  it,  drop  by  drop.  The  bowels 
are  likewise  obstinate,  and  never  act  without  medicines  or 
injections.     All  the  deeiJ  reflexes  are  greatly  exaggerated. 


Such  are  the  symptoms  which  may  be  observed  in  the 
first  stage  of  multiple  sclerosis  ;  and  this  stage  may  last 
from  two  to  six  years. 

The  second  period  of  the  disease  is  characterised  by 
aggravation  of  the  symptoms  of  the  first,  and  the  appear- 
ance of  spastic  paralysis.  The  patient,  who  has  until  then 
been  able  to  walk  about,  although  with  difficulty,  is  now 
reduced  to  the  condition  of  a  confirmed  invalid.  The  legs 
are  held  in  a  state  of  adduction,  and  the  feet  show  the  con- 
dition of  varo-equinus.  The  deep  refiexes  are  considerably 
exaggerated.  The  upper  extremities  are  generally  less 
severely  affected  than  the  lower  ones.  This  stage  may 
likewise  last  a  considerable  time,  viz.,  from  two  to  ten 
years. 

In  the  third  period  of  the  disease,  all  the  functions  of 
organic  life  show  signs  of  gradual  failure.  There  is  more 
or  less  complete  anorexia,  diarrhoea,  and  general  emaciation. 
The  mind  becomes  more  dull  and  confused,  and  the  speech 


378  SCLEROSIS  OF  THE  SPINAL  CORD. 

more  unintelligible,  until  the  patient  is  only  able  to  grunt. 
Apoplectiform  and  epileptiform  seizures,  which  we  have 
seen  to  occur  occasionally  in  the  first  stage,  are  now  very 
common.  Death  may  ensue,  with  symptoms  of  deep  coma, 
and  the  appearance  of  an  acute  bedsore  on  the  sacrum  ;  or 
the  patient  may  once  more  rally,  and  succumb  to  a  subse- 
quent attack.  In  other  cases  there  is  complete  marasmus  ; 
paralysis  of  the  sphincters  ;  gangrene  of  the  bladder  ; 
bedsores  in  various  parts,  and  blood-poisoning ;  or  the 
patient  is  carried  off  by  intercurrent  diseases,  such  as 
pneumonia,  phthisis,  and  dysentery. 


This  diagnosis  of  multiple  sclerosis  is,  like  those  of 
many  other  spinal  diseases,  sometimes  very  easy  and  at 
other  times  exceedingly  difficult.  We  have  already  dis- 
cussed the  peculiar  features  by  which  it  may  be  dis- 
tinguished from  shalcing  palsy  and  chorea  (p.  368).  From 
the  description  of  the  cases  which  have  been  given  in  this 
chapter,  it  will  be  seen  that  multiple  sclerosis  occasionally 
resembles  tabes  in  many  particulars.  There  may  be  initial 
apoplectiform  seizures ;  failure  of  mental  power ;  tem- 
porary or  permanent  affections  of  the  sensorial  nerves  ; 
various  forms  of  angesthesia  and  pareesthesia ;  a  gait  which, 
if  not  absolutely  identical  with  the  ataxic,  may  at  least 
closely  resemble  it ;  and  troubles  in  the  sphere  of  the 
bladder,  rectum,  and ,  sexual  organs,  as  well  as  gastric 
crises.  In  a  number  of  cases,  therefore,  we  shall  be  obliged 
to  rely  altogether  on  Westphal's  and  Argyll-Robertson's 
symptoms,  both  of  which  are  habitually  absent  in  multiple 
sclerosis.  Lightning-pains  are  likewise  exceedingly  rare, 
and,  if  present,  not  of  the  violent  aud  persistent  character 
which  they  habitually  assume  in  tabes. 

The  diagnosis  between  Friedreich's  disease  and  multiple 
sclerosis  may  occasionally  present  almost  insuperable  diffi- 
culties :   where  the    latter    occurs  in  children   or   persons 


MULTIPLE  OR  INSULAR  SCLEROSIS.  379 

about  the  age  of  puberty,  and  affects  the  posterior  columns 
with  preference,  such  a  distinction  may  indeed  be  impos- 
sible. In  most  cases,  however,  the  fact  that  in  Friedreich's 
disease  the  principal  symptom  is  ataxy,  and  in  multiple 
sclerosis  tremor,  as  well  as  the  opposite  state  of  the  deep 
reflexes  in  the  two  maladies,  will  be  sufficient  for  the 
diagnosis. 

Spastic  spinal  paralysis  resembles  multiple  sclerosis  more 
especially  in  the  second  stage,  when  there  is  paresis, 
rigidity,  and  increase  of  the  deep  reflexes.  The  absence 
of  the  peculiar  tremor  and  of  head-symptoms  will  gene- 
rally speak  in  favour  of  spastic  paralysis. 

A  symptom  which  I  consider  of  great  diagnostic  import- 
ance is  that  in  multiple  sclerosis  the  deep  reflexes  are 
often  quite  different  on  both  sides.  In  tabes  the  anatomical 
lesion  is  invariably  bilateral ;  and  although  one  side  of  the 
cord  is  often  more  severely  damaged  than  the  other,  yet 
even  the  less  affected  side  has  been  so  much  altered  as 
to  cause  the  knee-jerk  to  disappear.  There  is  therefore 
equal  loss  of  patellar  reflex  in  both  sides.  In  spastic  spinal 
paralysis  the  degree  of  exaggeration  of  the  deep  reflexes 
varies  occasionally,  but  not  habitually,  while  in  multiple 
sclerosis,  where  the  lesions  are  the  reverse  of  uniform, 
decided  differences  in  degree  are  the  rule  in  the  two  sides. 

Pseudo-sclerosis  (p.  67)  may  assume  many  symptoms  of 
multiple  sclerosis,  and  the  diagnosis  between  the  two  con- 
ditions would  appear  to  be  occasionally  almost,  if  not  quite, 
impossible. 

The  jyivffnosis  of  multiple  sclerosis  is  bad  when  the 
malady  has  become  fully  developed.  In  the  earlier  stages 
of  it,  however,  it  is  better.  The  patient  whose  case 
(No.  82)  is  described  on  p.  375  recovered,  under  the  influ- 
ence of  nitrate  of  silver  and  iodide  of  potassium,  from  all 
symptoms  excepting  the  unilateral  anosmia  and  deafness, 
which  remained  stationary,  but  did  not  trouble  him  much. 

The  treatment  of  multiple  sclerosis  is  still  in  its  infancy  ; 


380  SCLEROSIS  OF  THE  SPINAL  CORD. 

and  it  has  no  doubt  been  hitherto  unsuccessful  because 
remedies  of  which  good  may  be  expected  are  generally- 
employed  only  after  so  much  damage  has  been  done  that 
perfect  recovery  is  out  of  the  question.  Iodide  of  potassium, 
arsenic,  and  nitrate  of  silver  should  be  successively  admin- 
istered, while  a  careful  use  of  electricity  is  advisable  for 
the  purpose  of  strengthening  the  central  nervous  system 
against  further  inroads  of  the  disease. 


381 


CHAPTER  XVI. 

PSEUDO-SCLEROSIS. 

Pseudo-Sclerosis  is  a  term  proposed  by  Westphal  for 
those  probably  not  very  uncommon  cases  where  serious 
symptoms  of  nervous  disturbance  occur,  resembling  in  all 
respects  certain  forms  of  sclerosis  with  which  we  are 
familiar,  and  where  yet  after  death  no  palpable  lesions  are 
discovered  in  any  portion  of  the  nervous  system.  To  the 
cases  which  I  have  already  given  (p.  67)  the  following 
may  be  added  :  — 

A  midwife,  aged  thirty-nine,  who  had  for  several  years 
suffered  from  headache,  vertigo,  tremor,  and  paresis  in  the 
lower  extremities,  was,  on  admission  into  the  General 
Hospital  at  Vienna,  found  to  have  drawling  speech,  and  to 
answer  questions  in  an  unconnected  manner.  Convulsions 
were  occasionally  seen  in  the  muscles  of  the  body  and  the 
lower  extremities  ;  there  was  ataxy  in  the  left  hand,  and 
paresis  of  the  legs.  On  attempting  to  raise  the  legs  in 
bed  or  to  bend  the  knee,  muscular  spasms  supervened. 
The  patient  died  a  few  days  afterwards,  and  nothing  ab- 
normal was  discovered  in  any  portion  of  the  nervous 
system. 

The  following  case,  which  occurred  in  my  practice  a 
short  time  ago,  was  probably  one  of  pseudo-sclerosis  : — 

Case  84. — A  married  woman,  aged  thirty-eight,  and 
mother  of  five  children,  came  under  my  care  at  the  hos- 
pital in  April,  1883.  She  attributed  her  illness  to  having 
been  sitting  in  her  shop,  while  alterations  were  going  on, 
in  very  cold  weather,  and  having  felt  constant  chills  to  hei 


382  SCLEROSIS  OF  THE  SPINAL  CORD. 

back  during  that  time.  Shortly  afterwards  she  began  to 
have  shooting-pains,  like  electric  shocks,  running  through 
the  shoulders,  and  more  particularly  through  the  right 
arm.  She  also  complained  of  numbness  in  the  third  and 
little  finger  of  both  hands  ;  and,  on  testing  the  parts  with  a 
pin  and  the  sesthesiometer,  a  considerable  degree  of  anse- 
sthesia  and  analgesia  was  ascertained.  She  had  difficulty 
in  writing,  and  she  could  hardly  button  her  dress  on 
account  of  the  awkward  feeling  in  her  fingers.  She  had 
great  difficulty  in  walking,  could  not  walk  longer  than 
ten  minutes,  and  felt  numbness  in  the  lower  extremities. 
Romberg's  symptom  was  well  marked.  The  knee-jerk 
was  greatly  exaggerated  in  both  legs.  Menstruation 
was  regular  ;  the  bladder  and  rectum  appeared  in  their 
normal  condition  ;  and  there  was  no  affection  of  the  brain 
and  the  cranial  nerves.  I  put  the  patient  on  iodide  of 
potassium,  under  which  she  began  to  improve  almost  im- 
mediately ;  and  when  I  saw  her  last,  about  six  months 
afterwards,  she  was  in  all  respects  in  perfect  health. 

I  will  only  add  that  this  chapter,  like  that  on  sclerosis 
of  Groll's  columns,  has  yet  to  be  written. 

Ballet    and  Minor^  have  lately   used  the  term  "  fausse 
sclerose  "  for  combined  disease  of  the  posterior  and  lateral 
columns  ;  and  as  this  would  be  sure  to  lead  to  confusion, 
it  is  to  be  hoped  that  their  example  will  not  be  followed. 

^  *'  Archives  de  Neurologie,"  vol.  vii.,  p.  44.     Paris,  1884. 


383 


CHAPTER  XVII. 

COMBINED  POSTEEO-LATERAL  SCLEROSIS. 

This  is  at  present  one  of  the  least  studied  chapters  of 
spinal  pathology,  but  signs  are  not  wanting  that  our 
knowledge  of  it  will  soon  be  much  more  extended  than  it 
is  now. 

There  are  at  present  only  about  a  dozen  cases  on  record 
which  point  to  the  existence  of  this  disease  as  a  separate 
entity.  These  cases  have  been  described,  in  chronological 
order,  by  Kahler  and  Pick,^  Prevost,^  Westphal,^  Rabesiu/ 
Hamilton,^  Raymond,^  Damaschino/  and  Ballet  and 
Minor.^ 

In  analysing  these  cases,  which  present  considerable 
varieties  of  symptoms  as  well  as  of  anatomical  lesions,  it 
appears  that  we  have  in  all  of  them  to  do  with  a  simultane- 
ous affection  of  the  posterior  and  lateral  columns,  or  portions 
of  them,  without  any  simultaneous  lesion  of  the  central 
grey  matter.  There  is,  therefore,  no  simple  combination 
of  tabes  with  amyotrophic  lateral  sclerosis,  but  something 
essentially  different.  In  fact,  there  seems  to  be  every 
possible   combination  which  one  might  be  led  to  expect, 

'  ♦*  Archivfiir  Psychiatrie,"  vol.viii.,  p.  251,  and  vol.  x.,  p.  179.  1877. 
^  "Archives  de  Physiologie  normale  et  pathologique,"  p.  764.   Paris, 
1877. 
=*  **  Archiv  fur  Psychiatrie,"  vol.  ix.,  pp.  413,  691.     1878. 

4  Virchow's  "  Archiv,"  vol.  Ixxvi.,  p.  74.     Berlin,  1879. 

5  "  Medical  Record,"  vol.  xv.,  p.  481.    New  York,  1879. 

^'  *'  Archives  de  Physiologie  normale,"  etc.,  No.  7.     Paris,  1882. 

7  "  Comptes  Rendus,"  etc.     Paris,  1882. 

^  **  Archives  de  Neurologic,"  vol.  vii.,  p.  44.     Paris,  1884. 


384  SCLEROSIS  OF  THE  SPINAL  CORD. 

as  far  as  localisation  is  concerned,  while,  on  the  other 
hand,  the  nature  of  the  morbid  process  also  differs  con- 
siderably. 

1.  Perhaps  the  simplest  form  of  postero-lateral  sclerosis 
is  one  where  we  find  the  ordinary  lesions  of  tabes  com- 
bined with  wasting  of  the  direct  cerebellar  columns. 
This  constitutes  a  decided  system-disease,  inasmuch  as 
it  spares  all  the  other  parts  of  the  lateral  columns, 
with  the  only  exception  of  the  direct  cerebellar  strands 
(p.  25). 

2.  Another  form  consists  of  sclerosis  of  Burdach's 
columns,  which  after  a  time  becomes  complicated  with 
inflammation  of  the  pia  mater.  This  is  a  common  occur- 
rence in  tabes  (pp.  14  and  42)  ;  but  while  in  general  the 
leptomeningitis  appears  to  have  no  further  influence,  the 
inflammation  in  these  cases  spreads  from  the  pia  mater 
to  the  lateral  columns  in  a  more  or  less  diffuse  manner 
(cases  of  Prevost,  Kaymond,  and  Westphal). 

3.  A  third  form,  which  is  again  a  true  system-disease, 
consists  of  simultaneous  sclerosis  of  the  entire  posterior 
and  lateral  columns,  together  with  Tiirck's  direct  pyra- 
midal column,  which  was  found  affected  in  the  cervical 
and  dorsal  region  of  the  right  side  of  the  cord  (case  of 
Kahler  and  Pick).  In  this  case,  however,  the  subject  of 
which  was  an  ill- developed  girl  of  twenty  years  of  age,  it  is 
possible  that  we  may  have  had  rather  to  do  with  incom- 
plete development  than  with  actual  disease  of  the  spinal 
centre  (p.  13). 

4.  A  further  form  of  postero-lateral  sclerosis  is  one 
where  Burdach's  columns  appear  affected  chiefly  in  their 
dorsal,  and  much  less  in  their  lumbar  portion,  while  Golfs 
columns  are  found  diseased  in  the  cervical  region.  The 
lateral  columns,  in  their  turn,  are  not  systematically 
sclerosed,  either  in  the  direct  cerebellar  or  the  crossed  pyra- 
midal strands  ;  but  there  is  irregular,  diffuse,  and  un- 
systematic destruction  of  them,  resembling  more  multiple 


COMBINED  POSTEKO-LATERAL  SCLEROSIS.  385 

sclerosis  than  system-disease.  The  wasting  is  seen  to 
proceed  from  the  pia  mater  towards  the  centre  of  the 
cord,  traversing  the  direct  cerebellar  column,  and  encroach- 
ing upon  the  crossed  pyramidal  strand.  Wasting  of  the 
optic  nerves  has  accompanied  this  singular  lesion  (cases 
of  Rabesiu  and  Ballet  and  Minor). 

5.  Finally,  it  appears  that  diffuse  myelitis,  limited  to  a 
certain  area  of  the  cord,  may  lead  to  systematic  disease  of 
G  oil's  columns  above  the  seat  of  the  lesion,  and  of  the  pyra- 
midal strands  below  it.  To  this  may  be  added  sclerosis  of 
the  direct  cerebellar  columns.  (Cases  of  Grulliard,  quoted 
by  Ballet  and  Minor,  of  Pierret  and  Westphal.)  It  will 
be  seen  that  thes'e  cases  differ  completely  from  multiple 
sclerosis,  which  never  causes  any  secondary  degenerations, 
either  above  or  below  the  seat  of  the  lesion. 

The  symptoms  of  all  these  different  forms  of  sclerosis 
appear  to  be  very  similar,  and  constitute,  as  it  were,  the 
response  of  those  portions  of  the  posterior  and  lateral 
columns,  which  may  appear  to  be  affected,  to  the  morbid 
process.  The  nature  of  the  lesion  is  here  of  much  less  im- 
portance than  its  localisation.  On  the  one  hand,  we  know 
the  principal  signs  of  posterior  sclerosis  to  consist  of  affec- 
tions of  sensibility,  such  as  pain,  hypergesthesia,  anaesthesia, 
analgesia,  paraesthesia,  ataxy,  and  loss  of  deep  reflexes  ; 
while,  on  the  other  hand,  the  chief  symptoms  of  lateral 
sclerosis  have  been  seen  to  be  muscular  rigidity  and  paresis 
with  exaggerated  deep  reflexes.  Now  it  is  found  that,  simi- 
larly to  what  we  have  seen  to  occur  in  multiple  sclerosis, 
that  lesion  which  is  the  most  severe  and  extensive  will  im- 
part to  the  case  its  characteristic  aspect,  whether  posterior 
or  lateral.  Thus,  where  the  posterior  columns  are  de- 
stroyed in  the  lumbar  portion  of  the  cord,  there  must  be 
loss  of  the  knee-jerk,  with  flabby  condition  of  muscles, 
although  there  may  be  a  simultaneous  lesion  of  the  lateral 
columns  ;  and,  on  the  contrary,  where  those  and  other 
portions  of   Burdach's  columns    are    spared,  the   signs  of 

C  C 


386  SCLEROSIS  OP  THE  SPINAL  CORD. 

spastic  paralysis  will  be  present.  While,  therefore,  a 
singular  mixture  of  symptoms  may  be  observed  in  cer- 
tain cases,  a  diagnosis  of  the  principal  localisation  of  the 
disease  will  generally  be  possible  as  soon  as  it  has  become 
fully  established. 


THE    END. 


INDEX  OF  AUTHORS. 


A. 

Adamkiewicz,  45,  295. 
Allbutt,  284. 
Argyll-Eobertson,  155. 
Amdt,  42. 
Arthaud,  26. 
Aufrecht,  52. 


B. 


EaiUarger,  267,  382,  383. 

Ball,  215. 

BaUet,  196,  218. 

Bamberger,  303. 

Barron,  73. 

Bastian,  51,  64,  369. 

Baum,  320. 

Bechterew,  159, 

Benedict,  312,  319. 

Bennett,  67,  329. 

Berger,  3,  133,  319. 

Bernard  (Claude).  220,  244. 

Bernhardt,  81,  197,  319. 

BHlroth,  319. 

Bokai,  309. 

Bonjean,  68. 

Bouchard,  55. 

Bradbury,  121. 

Brandes,  315. 

Brenner,  313. 

Brissaud,  133. 

Bristowe,  365. 

Broadbent,  49. 

Brown- Sequard,  154,  334. 

Brunelli,  72. 

Buzzard,  37,  SI,  136,  190,  196,  218. 


C. 


Cahen,  341. 
Caizergues,  77. 


CC2 


Cantani,  72. 

Carpenter,  113. 

Carre,  113. 

Charcot,  3,  4,  9,  16,  19,  35,  36,  52, 
55,  61,  62,  63,  147, 148,  151,  175, 
176,  186,  216,  283,  306,  317,  341, 
347,  363,  366,  369,  374. 

Chauvet,  89. 

Cherchevsky,  186,  189. 

Clark,  Sir  Andrew,  287. 

Clarke,  Lockhart,  15. 

Combal,  317. 

Cruveilhier,  189,  255. 


D. 


Damascbino,  383. 

Debove,  196. 

Dejerine,  34. 

Dolamore,  191. 

Demange,  186,  219. 

De  Wecker,  322. 

Dowse,  146. 

Dragendorf,  68. 

Dreschfeld,  3,  51,  77, 113,  189,  217. 

Dreyfus -Brissac,  186. 

DrosdofP,  205. 

Drysdale,  77. 

Ducastel,  60,  362. 

Duchenne,  2,  38,  76,  92,  130,  224, 

233,  290,  310. 
Duplay,  215. 
Dutn,  218. 


E. 

Ebstein,  220. 

Eichhorst,  293. 

Eisenmann,  212. 

Erb,  2,  3,  57,  80,  81,118,  133,  136, 

151,  157,  205,  239,  257,  312,  332, 

344. 
Erlitzky,  28. 


388 


INDEX  OF  AUTHORS. 


Eulenburg,  112,  120,  133,  145,  258, 

260,  310. 
Exner,  16. 


F. 


Falret,  267. 

Fayard,  215. 

Fereol,  186. 

Ferrier,  169,  348. 

Fleehsig,  6,  59. 

Fluger,  319. 

Fournier,  76,  81,  86,  100,  115,  137, 

148. 
Friedreich,   65,   66,  112,  114,  239, 

308,  324. 
Friedlander,  303. 


G. 

Gralezowski,  174,  284,  322. 

Gerlach,  15,  17. 

Gnauk,  374. 

Goltz,  243. 

Gowers,  60,  77,81,-113,  133,  362. 

Graefe,  A.  Von,  163. 

Grasset,  77,  306,  316. 

Gubler,  112. 

Gulliard,  385. 

Gussenbauer,  319. 


H. 

Hadden,  58. 
Hahn,  319. 
Hamilton,  309,  383. 
Hammond,  66,  95,  299. 
Hanot,  215. 
Hayem,  28. 
Hempel,  161. 
Henck,  344. 
Heschl,  57. 
Hansen,  166. 
Heyd,  245. 
Hippocrates,  223. 
Hirschfelder,  319. 
Hopkin«,  52,  341. 
Husemann,  308. 
Hutchinson,  77,  163,  165. 


J. 


Jadersholm,  40. 


K. 


Kahler,  13,  29,  61,  65,  111,  167,  383. 

Key,  Axel,  28. 

Kiwatkowski,  280. 

Klein,  63. 

Krehmer,  308. 

Krishaber,  186,  188. 

Kundrat,  58. 

Kiimmell,  322. 


Lancereaux,  89,  109. 

Langenbucli,  30,  318. 

Langerhans,  34. 

Lecoq,  186,  197. 

Leubuscher,  121. 

Lewis,  Bevan,  16,  17,  25,  44. 

Leyden,  3,  22,  30,  57,  80,  95,  240, 

258,  290. 
Liegeois,  303. 
Liouville,  308. 
Lowenfeld,  312. 
Luys,  22. 


M. 

Mackenzie,  190. 

Magnan,  267,  268. 

Marie,  183. 

Marshall,  320. 

Martindale,  307. 

Meschede,  58. 

Meyer  (Moritz),  312. 

Minkowsky,  53, 

Minor,  382,  383. 

Mitchell,  218. 

Mobius,  121,  139. 

Moos,  180. 

Morat,  215. 

Morgan,  51. 

Miiller  (Gratz),  67,  319,  330. 

Miiller  (Wiesbaden),  202. 


N. 

Neftel,  38,  313. 
Nikitin,  68. 
Nussbaum,  317,  320. 


INDEX  OF  AUTHORS. 


389 


0. 


Ollivier,  308. 
Ordonez,  44,  64. 
Ormerod,  183. 

P. 
Page,  40,  215. 
Pavy,  281. 
Petit,  104. 

Pick,  13,  65,  111,  167,  383. 
Pierret,  9,   19,   22,  24,  28,  29,  34, 

48,  60,    149,  150,   184,   240,  362, 

385. 
Pitres,  31,  41,  52. 
Podwissotzki,  68. 
Poucet,  27. 
Prevost,  383. 
Privat,  316. 
PusineUi,  81. 
Putnam,  220. 


Quinquano,  81. 


Q. 


E. 


Eabesiu,  383. 

Eanvier,  16,  154. 

Eaymond,  26,  383. 

Eemak,  sen.,  158,  220,  312. 

Eemak,  jun.,  319. 

Eetzius,  28. 

Eeumont,  315. 

Eey,  267. 

Eicord,  291. 

Eiegner,  319. 

Eiemer,  309. 

Eomberg,  76,  101,  229,  290,  321. 

Eosenheim,  134. 

Eosenthal,  310,  314. 

Eoss,  51,  58,  81. 

Eougier,  267,  269. 

Eumpf,  94,  310. 

Ptussell,  51. 

Eutherford,  16. 

S. 
Sachs,  133. 
Schieferdecker,  293. 
Schiff,  240,  243,  254,  257. 
Schiile,  365. 

Schultze,  13,  52,  55,  342,  344. 
Schumacher  II.,  315. 
Schuster,  275. 


Seeligmiiller,  324. 
Semon,  189,  190. 
Singer,  61. 
Socin,  319. 
Southam,  213,  345. 
Squire,  307. 
Stadelmann,  61. 
Stern,  303. 
Stintzing,  320. 

Striimpell,  9,    19,  20,  42,    65,  145, 
253,  336,  370. 

T. 

Tacasz,  40. 
Targioni-Tozzetti,  72. 
Teissier,  272. 
Thibierge,  215. 
Todd,  223,  353. 
Topinard,  117,  151,  258. 
Treves,  215. 
Tschirjew,  133. 
Trousseau,  2,  112,  121,  290. 
Tiirck,  30. 
Tweedy,  309. 
Tuczek,  40,  42,  68. 


Vaillard,  31,  41. 

Van  Deen,  241. 

Van  der  Velden,  344. 

Vidal,  112. 

Vierordt,  245. 

Vincent,  157,  159. 

Voelcker,  166. 

Vogt,  317. 

Von  Bruns,  37. 

Vulpian,  2,  9,  16,  19,  22,  26,  31,  39, 

44,  62,  76,  81,137,  152,154,  186, 

192,  259,  261,  290. 


W. 

Waldmann,  42. 

Walle,  114. 

Walton,  183. 

Wenzell,  68. 

Westphal,  31,  40,   67,   80,  89,  124, 

132,  145,  197,208,  318,  346,381, 

383,  385. 
Williams,  10. 
WoroschilofF,  244. 
Wunderlich,  306. 


INDEX  OF  SUBJECTS. 


A. 


Abductors  of  vocal  cords,  paralysis 
of,  in  tabes,  189. 

Accidents,  as  causes  of  tabes,  104  ; 
of  spastic  paralysis,  125. 

Achromatopsia,  175. 

Acute  ataxy,  235. 

Acute  diseases  causing  tabes,  111  ; 
spastic  paralysis,  125. 

Age,  influence  of,  in  causing  tabes, 
117 ;  spastic  paralysis,  125 ; 
Friedreich's  disease,  113;  mul- 
tiple sclerosis,  128. 

Aix-la-Chapelle  treatment  of  tabes, 
85,  86,  264,  266,  305,  315. 

Amaurosis,  172. 

Amblyopia,  172,  373. 

Amyotrophic  lateral  sclerosis,  4,  61  ; 
causes  of,  129  ;  symptoms  of,  347  ; 
diagnosis,  prognosis,  and  treat- 
ment of,  349. 

Ansesthesia,  202,  251. 

—  dolorosa,  256. 
Analgesia,  254. 
Anidrosis,  220. 
Ankle-clonus,  334. 
Anosmia,  167,  375. 
Aphasia,  194. 
Aortic  disease,  272. 

Argyll- Robertson's  symptom,  155. 
Argyria,  308. 

Arthropathy,  35,  216,  278. 
Aspermatism,  213. 
Ataxic  gait,  230. 

—  stage  of  tabes,  222. 

Ataxy,  locomotor,  223  ;  static,  226  ; 
theory  of,  239. 

—  of  ocular  muscles,  237. 
Atrophy,  muscular,  219. 
Auditory    nerve,    sclerosis   of,    28 ; 

affections  of,  176. 
Axis -cylinder  in  tabes,  47  ;    mul- 
tiple sclerosis,  63. 


B. 


Baraesthesiometer,  260. 
Bladder,  affections  of,  206,  286, 376. 
Bowels,  affections  of,  209,  376. 
Brain,  lesions  of,  26  ;  supposed  seat 

of    tabes,    38 ;    syphilis  of,    94; 

early  affections  of,  in  tabes,  194  ; 

late  affections  of,  263. 
Burdach's  columns,  evolution  of,  8  ; 

lesions  of,  19,  243. 


C. 


Cardiac  crises,  194. 
Cerebellar  strands,  vide  Direct  cere- 
bellar strands. 
Cerebellum,  supposed  seat  of  tabes, 

38  ;  its  part  in  static  ataxy,  249  ; 

disease  of,  confounded  with  tabes, 

288. 
Cerebral  troubles  in  tabes,  194,  263. 
Chorea  confounded  with  tabes,  287  ; 

with  multiple  sclerosis,  368. 
Clarke's  vesicular  columns,  lesions 

of,  24. 
Combined  system -diseases,  65,  383. 
Cold,  cause  of  tabes,  99. 
Cochleary  nerve,  sclerosis  of,   28 ; 

affections  of,  182, 
Colour-blindness,  175. 
Constipation,  209. 
Corns,  supposed  cause  of  tabes,  40, 

215. 
Counter-irritation  for  tabes,  321. 
Cranial    nerves,     sclerosis   of,    26; 

affections  of,    in  tabes,  155 ;   in 

spastic  paralysis,  342  ;  in  multiple 

sclerosis,    371  ;     in    Friedreich's 

disease,  324. 
Crossed  pyramidal  strands,  evolution 

of,  11  ;  lesions  of,  51 ;  affections 

of,  350. 


INDEX    OF    SUBJECTS. 


391 


Crises,  cardiac,   194;  gastric,    191; 

intestinal,  210  ;    laryngeal,  186  ; 

vesical,  208. 
Cutaneous  eruptions,  218. 
Cycloplegia,  165. 


D. 


Daltonism,  175,  373. 

Deafness,  177,  375. 

Delayed  sensation,  256. 

Descending  lateral  sclerosis,  350. 

Diabetes  confounded  with  tabes,  278. 

Diarrhoea,  210,  221. 

Direct  cerebellar  strands,  evolution 

of,  10  ;  sclerosis  of,  60,  384. 
Double  vision,  161. 
Drawling  speech,  371. 
Drink  as  a  cause  of  tabes,  110. 
Dynamometer  for  lower  extremities, 

233,  329. 
Dyschromatopsia,  175. 


E. 


Electricity  in  tabes,  310  ;  in  hemi- 
plegia, 356 ;  in  spastic  spinal 
paralysis,  345  ;  in  multiple  scle- 
rosis, 380. 

Enteralgia  confounded  with  tabes, 
284. 

Epileptic  fits,  197. 

Ergotism,  5,  68. 

Ergot  of  rye  in  tabes,  305. 

Etiology  of  tabes,  68  ;  Friedreich's 
disease,  112 ;  spastic  paralysis, 
122 ;  multiple  sclerosis,  127 ; 
amyotrophic  lateral  sclerosis,  129. 

Evolution  of  spinal  cord,  6. 


F. 


Failure  of  brain  power,  198. 

Faradisation, 310 ;  faiadic  baths,  314. 

"  Fausse  sclerose,"  382. 

Fifth  nerve,  sclerosis  of,  28;  affec- 
tions of,  183. 

Fracture  of  patella  and  knee-jerk, 
135. 

Friedreich's  disease,  05  ;  causes  of, 
112;  symptoms  of,  324;  diagno- 
sis, prognosis  and  treatment  of, 
327,  378. 


G. 


Galvanic  baths,  314. 

Galvanism,  vide  Electricity. 

Gastein  in  tabes,  315. 

Gastralgia  confounded  with  tabes, 
284. 

Gastric  crises,  191. 

Gastrorrhoea,  221. 

General  paralysis  of  the  insane,  266. 

Girdle- sensation,  201. 

Glossopharyngeal  nerve,  sclerosis  of, 
29  ;  affections  of,  185. 

Glycosuria,  263,  195,  341. 

Goll's  columns,  evolution  of,  9 ; 
lesions  of,  Ip,  44,  60,  242  ;  pri- 
mary sclerosis  of,  362. 

Gout  confounded  with  tabes,  139, 
277. 

Grey  matter  of  the  cord,  lesions 
of,  22. 


H. 


Heine's  invocation,  273. 
Hemi-ansesthesia,  245. 
Hemi-ataxy,  146,  238. 
Hemi-atrophy  of  tongue,  185. 
Hemiplegia,  194,  343,  350. 
Hereditary  ataxy,  65. 
Hydropathic  treatment  of  tabes,  314. 
Hypereesthesia,  200. 
Hyperidrosis,  220. 
Hyperosmia,  172. 
Hysteria,  276,  330,  343. 


Ichthyosis,  218. 

Impotency,  2 LI. 

Incontinence  of  urine,  207 ;  of 
faices,  210. 

Injection  of  mercury,  302  ;  of  sil- 
ver, 310. 

Insane,  general  paralysis  of,  268, 
289. 

Insular  sclerosis,  vide  Multiple 
sclerosis. 

Intestinal  affections,  209  ;  crises, 
210. 

Iodide  of  potassium  in  tabes,  303 ; 
hemiplegia,  357  ;  multiple  scle- 
rosis, 375. 


392 


INDEX    OP    SUBJECTS. 


Iridoplegia,  165. 
Irritable  spine,  276. 
Itching,  218. 


J. 


Jungle-fever  cause  of  tabes,  111. 


K. 

Knee-jerk,  its  diagnostic  import- 
ance, 71  ;  loss  of,  132;  exaggera- 
tion of,  334,  376. 


L. 


Labio  -  glosso  -  laryngeal   paralysis, 

349. 
La  Malou  for  tabes,  316. 
Laryngeal  crises,  186. 
Lateral  columns,  lesions  of,  in  tabes, 

25  ;  primary  sclerosis  of,  51,  55. 
Lathyrism,  5,  71. 


Nerve-stretcbing  for  tabes,  317, 
322  ;  for  spastic  paralysis,  345. 

Neuralgia,  284. 

Neurasthenia,  275. 

Neurotic  constitution,  anatomical 
bases  of,  13  ;  cause  of  tabes.  111 ; 
of  spastic  paralysis,  123;  of  mul- 
tiple sclerosis,  128. 

Nitrate  of  silver  in  tabes,  306. 

Numbness,  250. 

Nymphomania,  213. 

Nystagmus,  324,  372. 


0. 


162 


Ocular  muscles,  paralysis  of, 
ataxy  of,  237. 

Oeynhausen  in  tabes,  315. 

Olfactory   nerve,   sclerosis   of,    26 ; 
affections  of,  167. 

Ophthalmoplegia  externa,  163 ;  in- 
terna, 165. 

Optic  nerve,  sclerosis  of,  26  ;  atrophy 
of,  172,  283 ;  treatment  of,  322. 

Over-exertion   causing   tabes,    103 ; 
spastic  paralysis,  126. 


M. 


Masturbation  causing  tabes,  109, 

Meningitis  spinalis,  14,  42,  288. 

Menstruation  in  tabes,  213  ;  in  mul- 
tiple sclerosis,  376. 

Mental  affections,  198. 

Mineral  waters  in  tabes,  315. 

Motility  in  tabes,  205. 

Monoplegia,  194. 

Multiple  sclerosis,  pathology  of,  62  ; 
causes  of,  127  ;  symptoms  of,  363; 
diagnosis  of,  378;  prognosis  and 
treatment  of,  379. 

Muscular  sensibility  in  tabes,  261. 

Mydriasis,  160. 

Myosis,  155. 


N. 


Nails,  malnutrition  of,  219. 
Nauheim  in  tabes,  315. 
Nerve  of   space,   sclerosis  of, 
affection  of,  181. 


28 


P. 


Paraesthesia,  201. 

Paralysis,  agitans,  288,  368 ;  of 
ciliary  muscle,  160  ;  of  abductors 
of  vocal  cords,  189  ;  ocular 
muscles,  161,  371 ;  sixth  nerve, 
162 ;  third  nerve,  162  ;  fourth 
nerve,  163 ;  pharyngeal  nerve, 
191 ;  cerebral,  194  ;  spastic  spinal, 
vide  Spastic  spinal  paralysis. 

Parkinson's  disease,  288,  368. 

Perforating  ulcer  of  foot,  213. 

Periods  of  tabes,  130;  of  multiple 
sclerosis,  377. 

Perspiration,  suppression  of,  as  cause 
of  tabes,  116. 

Pia  mater,  inflammation  of,  14,  42. 

Porencephaly,  57,  359. 

Portio  dura,  paralysis  of,  185. 

Posterior  nerve -roots,  lesions  of, 
21  ;  physiology  of,  244. 

Posterior  root-zones,  lesions  of,  8, 
19. 

Posterior  sclerosis,  vide  Tabes. 


INDEX  OF  SUBJECTS. 


393 


Postero-extemal  columns,  vide  Bur- 

dach's  columns. 
Postero- internal  columns,  vide  Goll's 

columns 
Postero-lateral  sclerosis,  383. 
Pre-ataxic  stage  of  tabes,  130. 
Pressure,  loss  of  sense  of,  260. 
Progressive  muscular  atrophy,  349. 
Pseudo-knee-jerk,  145. 
Pseudo- sclerosis,  67,  279,  381. 
Ptosis,  162. 

Pupil,  affections  of,  155,  289. 
Pyramidal    strands,     vide     Crossed 

pyramidal  strands. 


R. 


Keflexes,  superficial,  262;  deep,  132, 
262,  334,  376  ;  different  types  of, 
337. 

Rheumatism,  116,  277. 

Romberg's  symptom,  229. 


Spermatorrhcea,  213. 

Spinal  accessory  nerve,  sclerosis  of, 

29;  affection  of,  194. 
Spinal  epilepsy,  335. 
Spinal  ganglia,  lesions  of,  in  tabes, 

22. 
Spinal  membranes,  14,  42,  288. 
Spinal  nerves,  sclerosis  of,  30. 
Stages    of   tabes,    130;    first,  131; 

second,  222  ;  third,  263  ;  of  spastic 

spinal  paralysis,  328  ;  of  multiple 

sclerosis,  377. 
Stomach,    diseases    of,    confounded 

■with  tabes,  285. 
Strychnia    for    tabes,    321  ;  lateral 

sclerosis,  357. 
Sympathetic  system  of  nerves,  scle- 
rosis   of,    26 ;    supposed   seat   of 

tabes,  39. 
Syphilis  causing  tabes,  74  ;  spastic 

paralysis,  124  ;  its  treatment,  291, 

302. 
Systems  of  the  spinal  cord, '5. 


S. 

Satyriasis,  212. 

Sclerosis,  definition  of,  2  ;  posterior, 
2,  14  ;  lateral,  3,  51  ;  multiple, 
62, 363 ;  secondary  or  descending, 
4,  68,  350,  360. 

Sclerotic  tremor,  366. 

Sclerotinic  acid,  68. 

Scotomata,  175. 

Sensibility  in  tabes,  199,  250  ;  in 
spastic  paralysis,  339  ;  in  multiple 
sclerosis,  365. 

Secondary  lateral  sclerosis,  350,  360. 

Sewing-machine,  influence  of,  in 
causing  tabes,  109. 

Sex,  influence  of,  in  production  of 
tabes,  121 ;  spastic  paralysis,  123. 

Sexual  troubles  in  tabes,  211. 

Sialorrhcea,  221. 

Sixth  nerve,  palsy  of,  162. 

Spaeth- Schiippel's  case,  239. 

Spasmodic  tabes  dorsalis,  vide  Spas- 
tic spinal  paralysis. 

Spastic  gait,  332. 

Spastic  spinal  paralysis,  3,  51  ; 
causes,  122  ;  symptoms  of,  328  ; 
diagnosis  of,  342  ;  prognosis  and 
treatment  of,  344 ;  in  children, 
358. 


T. 


Tabes,  morbid  anatomy  of,  14 ; 
pathogenesis  of,  38 ;  etiology  of, 
68  ;  symptoms  of,  130  ;  diagnosis 
of,  275  ;  prognosis  of,  290  ;  treat- 
ment of,  299. 

Teeth,  malnutrition  of,  219. 

Teplitz  in  tabes,  315. 

Temperature,  loss  of  sense  of,  257. 

Tests  for  discovering  ataxy,  226. 

Thermsesthesiometer,  258. 

Third  nerve,  sclerosis  of,  27 ;  palsy 
of,  162. 

Tickling,  loss  of  sense  of,  260. 

Tinnitus,  183. 

Tobacco-smoking  causing  tabes,  110. 

Torticollis,  194. 

Transverse  myelitis,  343. 

Tremor,  366. 


U. 

Ulcer,  perforating,  of  foot,  213. 
Urethral  diseases    confounded  with 

tabes,  286. 
Urine  in  tabes,  263. 


394  INDEX  OF  SUBJECTS. 

V.  w. 

Vago-accessory  nerve,    sclerosis  of,       Wallerian  degeneration,  31. 

29  ;  affections  of,  186.  Weir-Mitchell  treatment,  345. 

Vasomotor  symptoms,  220.  Westphal's  symptom,  132. 

Venereal  excesses  causing  tabes,  108.       "Wildbad  for  tabes,  315. 
Vertigo,  182,  371. 
Vesical  crises,  208. 
Vestibulary  nerve,  sclerosis  of,  29; 

affection  of,  181. 


WEKTHEIMEB,   LEA   AND   CO.,   PEINTEES,  CIRCUS  PLACE,   LONDON  WALL, 


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On  sclerosis  of  the  spinal 
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